Does physician benchmarking improve performance of laparoscopically assisted vaginal hysterectomy?Background: Benchmarking techniques were implemented to optimize operating time and charges associated with laparoscopically assisted vaginal hysterectomy vaginal hysterectomy n. The surgical removal of the uterus through the vagina without incising the wall of the abdomen. vaginal hysterectomy (LAVH LAVH Laparoscopic Assisted Vaginal Hysterectomy ). Materials and Methods: The baseline LAVH profile over a period of 4 years (167 cases) was compared with 1-year data (47 cases) after a benchmarking educational program (disseminating data ranking performance by each surgeon plus suggestions for improvement). Preintervention and postintervention profiles were compared by means of Student t test and wilcoxon rank sum analysis. Hierarchical multiple regression Multiple regression The estimated relationship between a dependent variable and more than one explanatory variable. was used to identify additional sources of variation for operative charges and time. Results: Mean operating times after implementing benchmarking were lower, averaging 182 versus 197 minutes in the control subjects (P = 0.05). We found no significant difference in total or operative charges. After adjusting for potential confounders, benchmarking remained associated with decreased operating time in the multivariate model (P = 0.01). Conclusions: LAVH operating times decreased after a surgical benchmarking and education intervention, but operating charges did not. Key Words: quality improvement, laparoscopy laparoscopy or peritoneoscopy Procedure for inspecting the abdominal cavity using a laparoscope; also surgery requiring use of a laparoscope. Laparoscopes use fibre-optic lights and small video cameras to show tissues and organs on a monitor. , hysterectomy hysterectomy (hĭstərĕk`təmē), surgical removal of the uterus. A hysterectomy may involve removal of the uterus only or additional removal of the cervix (base of the uterus), fallopian tubes (salpingectomy), and ovaries ********** Laparoscopic-assisted vaginal hysterectomy (LAVH) remains a controversial hybrid approach to definitively treat common gynecologic gynecologic /gy·ne·co·log·ic/ (gi?ne-) (jin?e-kah-loj´ik) pertaining to the female reproductive tract or to gynecology. problems when conservative measures fail. Although experts suggest that potentially 80% of all hysterectomies could be performed vaginally, by inference. 20% of cases are LAVH candidates. (1,2) In addition, physician inexperience with vaginal surgery may further expand the role of laparoscopy in performing hysterectomy. In comparison studies, vaginal hysterectomy consistently results in faster recovery and decreased charges compared with abdominal hysterectomy abdominal hysterectomy n. A hysterectomy made through an incision in the abdominal wall. Also called abdominohysterectomy. abdominal hysterectomy . With LAVH, those differences become less clear. (3,4) Criticism of this procedure centers on the added expense and time of a two-stage surgical procedure as well as the frequent use of costly, disposable endoscopic en·do·scope n. An instrument for examining visually the interior of a bodily canal or a hollow organ such as the colon, bladder, or stomach. en equipment. In experienced hands, costs and times incurred with LAVH are reportedly closer to that of total vaginal hysterectomy. (5) Studies comparing LAVH with vaginal and abdominal hysterectomy have focused on overall charges, length of stay, and morbidity. Further work in increasing LAVH efficiency might help reduce associated costs and time, much like with cesarean section cesarean section (sĭzâr`ēən), delivery of an infant by surgical removal from the uterus through an abdominal incision. The operation is of ancient origin: indeed, the name derives from the legend that Julius Caesar was born in this . (6) The objective of total quality management as applied to health care is delivery of optimal outcomes while upholding cost containment cost containment, n the features of a dental benefits program or of the administration of the program designed to reduce or eliminate certain charges to the plan. . The use of statistical analysis to identify sources of variation in medical practice has evolved from quality management techniques originally derived for manufacturing processes, as associated with W. Edwards Demings' work with the Japanese automobile industry Japan is the world's largest automobile manufacturer and exporter, and has six of the world's ten largest automobile manufacturers. In addition to its massive automobile industry, Japan also is the home to manufacturers of other types of vehicles, like powersports vehicle manufacturers . (7) Benchmarking represents one of these strategies in which practitioners are provided with quantitative feedback on their performance relative to their peers. Data from studies of ophthalmologists and general surgeons suggest that this feedback can positively mold physician behavior toward shorter operative times. (8) The quality management approach differs from the traditional methods of changing medical practice that are rooted in punitive actions for suboptimal Suboptimal A solution is called suboptimal if a part of the solution has been optimized without regards to the overall objective. outcomes; awareness of differences between average and best practices, within an institution, instead, is the initial step in achieving improvement goals. To improve efficiency, and specifically the LAVH procedure at our hospital, we addressed the following research questions: (1) Does physician benchmarking decrease the operative charges and time associated with performance of LAVH? (2) What are the patient and physician factors that influence how benchmarking affects these operative outcomes? Materials and Methods Between January 1996 and May 2000, 167 LAVHs were performed by a total of 46 gynecologic attending surgeons at Prentice Women's Hospital Women's Hospital of Greensboro (part of Moses Cone Health System) As the state's first free-standing hospital dedicated to women, the Women's Hospital of Greensboro is a 134-bed hospital is dedicated to providing state-of-the-art, compassionate and personalized care to women in Chicago, Illinois. Women were identified through the use of hospital surgical databases containing diagnoses, procedures, and operative time. The preintervention group consisted of all surgical cases assigned the ICD-9-CM ICD-9-CM International Classification of Disease, 9th edition, Clinical Modification A standardized classification of disease, injuries, and causes of death, by etiology and anatomic localization and codified into a 6-digit number, which allows code 68.51 (LAVH) beginning January 1996 and ending May 2000. The postintervention group consisted of all cases performed during the subsequent year, as described below. The medical center finance department provided each case's clinical charge information. The first author reviewed operative reports for all cases coded for LAVH. Operative time in the database was recorded as total time in the operating room operating room n. Abbr. OR A room equipped for performing surgical operations. . Based on review of operative reports, cases erroneously coded, converted to open surgery, or involving additional procedures for cancer, prolapse prolapse Protrusion of an internal organ out of its normal place, usually of the rectum or uterus outside the body when supporting muscles weaken. The membrane lining the rectum can push out through the anus, most often in old people with constipation who strain during , or incontinence were excluded. The initial control group of cases was used to generate baseline descriptive data and rank-order performance profiles for LAVH operating time and charges. The summary data indicating charges and time for each individual practitioner and individual rank score in this interval were mailed to all surgeons in May of 2000. Each individual was thus aware of their overall rank within the group and the composite group profile but not the specific individual rankings and profiles for other surgeons. In addition, the per-minute cost of operating room time, charges associated with all currently available disposable equipment, as well as suggestions for decreasing costs through conservative usage of disposable surgical equipment were included. A follow-up letter follow-up letter n → carta recordatoria was mailed out reiterating these suggestions 8 months later. During the 12-month study period, 24 attending gynecologic surgeons performed an additional 47 cases meeting criteria that were identified and analyzed similarly to the control cases. Of these 24 surgeons, 14 had also contributed cases to the initial baseline evaluation. The Northwestern University Northwestern University, mainly at Evanston, Ill.; coeducational; chartered 1851, opened 1855 by Methodists. In 1873 it absorbed Evanston College for Ladies. Feinberg School of Medicine The Feinberg School of Medicine is one of Northwestern University's 11 schools and colleges. It is a prestigious American medical school located in the Streeterville neighborhood of Chicago, Illinois, situated near Lake Michigan and the Magnificent Mile. Institutional Review Board approved this research project. In keeping with the principles of quality improvement, physicians with substandard operating performance were not penalized pe·nal·ize tr.v. pe·nal·ized, pe·nal·iz·ing, pe·nal·iz·es 1. To subject to a penalty, especially for infringement of a law or official regulation. See Synonyms at punish. 2. , as access to all study data was restricted to the authors. Quality improvement philosophy requires that evaluation and improvement of practice be directed to all personnel and systems involved. The educational effort to decrease the use of unnecessary disposable equipment and shorten operating times involved all operating room staff. Similarly, resident physicians rotating on the gynecology service regularly discussed these principles during weekly endoscopy endoscopy Examination of the body's interior through an instrument inserted into a natural opening or an incision, usually as an outpatient procedure. Endoscopes include the upper gastrointestinal endoscope (for the esophagus, stomach, and duodenum), the colonoscope (for the rounds overseen by the senior author. (9) Both residents and surgical staff helped to reinforce cost-consciousness and discourage the use of disposable equipment when unnecessary. We reviewed individual patient charts for preoperative pre·op·er·a·tive adj. Preceding a surgical operation. preoperative preceding an operation. preoperative care the preparation of a patient before operation. diagnoses and relevant medical history: previous cesarean sections, normal vaginal deliveries, and parity. Operative reports were reviewed where possible (n = 213) to determine if intra-abdominal adhesions were present. Final surgical pathology surgical pathology n. A field in anatomical pathology concerned with examination of surgical specimens of tissues removed from living patients for the purpose of diagnosis of disease and guidance in the care of patients. was also reviewed, with the exception of one missing report, and uterine uterine /uter·ine/ (u´ter-in) pertaining to the uterus. u·ter·ine adj. Of, relating to, or in the region of the uterus. weights were recorded when available (n = 195). A previously assembled administrative database of physician experience in all endoscopic procedures from 1998 to 2000 was obtained from department data. Descriptive data were tabulated for the pre--and postintervention groups. Because the distribution of charge data is positively skewed skewed curve of a usually unimodal distribution with one tail drawn out more than the other and the median will lie above or below the mean. skewed Epidemiology adjective Referring to an asymmetrical distribution of a population or of data , medians are reported. The Student t test and Wilcoxon rank-sum test were used to compare time and cost characteristics for the two groups. Bivariate bi·var·i·ate adj. Mathematics Having two variables: bivariate binomial distribution. Adj. 1. analyses comparing cost and time with covariates were conducted by using correlation analysis and Student t test. To determine a more precise estimate of the association between the predictor and our operative outcomes, candidate confounders were examined. Subsequently, we performed multiple regression analysis to calculate adjusted mean charges and operating times for the two groups. STATA version 7.0 (College Station, TX) was used for all statistical analysis. Results Summary statistics before and after the intervention are shown in Table 1. Mean uterine weights and physician laparoscopic Laparoscopic A minimally-invasive surgical or diagnostic procedure that uses a flexible endoscope (laparoscope) to view and operate on structures in the abdomen. Mentioned in: Obstetrical Emergencies experience were significantly higher in the preintervention groups. No other factors significantly differed on univariate analysis. In both groups, the most common operative indications were symptomatic leiomyomata and menorrhagia menorrhagia /men·or·rha·gia/ (men?ah-ra´jah) hypermenorrhea. men·or·rha·gia n. See hypermenorrhea. , as shown in Table 2. Other than proportion of diagnosis of chronic pelvic pain Women and Pelvic pain Most women (and some men), at some time in their lives, experience pelvic pain. When the condition persists for longer than 3 months, it is called chronic pelvic pain (CPP). , which approaches significance, and adnexal adnexal /ad·nex·al/ (ad-nek´sal) pertaining to adnexa. adnexal pertaining to, or emanating from, the adnexa. adnexal tumors disease, the two groups did not differ. Pathologic findings were similar between the two groups; leiomyomata and adenomyosis adenomyosis /ad·e·no·my·o·sis/ (-mi-o´sis) benign ingrowth of the endometrium into the uterine musculature, sometimes with hypertrophy of the latter; if the lesion forms a circumscribed tumorlike nodule, it is called adenomyoma. were most commonly encountered, whereas roughly one fifth of women in both groups had pelvic adhesions noted. Endometriosis endometriosis (ĕn'dəmē'trē-ō`sĭs), a condition in which small pieces of the endometrium (the lining of the uterus) migrate to other places in the pelvic area. was encountered with higher frequency in the postintervention group. Table 3 summarizes the results of analyses comparing charges and operating time between the two groups. Mean procedure times were significantly shorter for the procedures after benchmarking, a difference of 16 [+ or -] 8 minutes. We accounted for inflation by referencing the medical care portion of the US Consumer Price Index (CPI (1) (Characters Per Inch) The measurement of the density of characters per inch on tape or paper. A printer's CPI button switches character pitch. (2) (Counts Per I ). standardizing charge data relative to 2001 values. (10) All subsequent analyses used these CPI-adjusted financial figures. No differences were noted in laboratory, pharmacy, or other miscellaneous charge categories. To address the physician-specific impact of benchmarking, a subset of cases restricted to the 14 physicians who operated both before and after the intervention was analyzed separately, totaling 118 cases (82 before, 36 after). An associated decrease in operating time remained (200 minutes [95% CI, 191, 210] vs 183 minutes [95% CI, 166, 199], P = 0.06), with a trend toward significance; no difference was identified in total charges or equipment charges. For the final models, mean equipment charges as shown in Table 4 are adjusted for uterine weight, whereas both operative time and total operating charges are adjusted for physician volume and uterine weight. As a potential confounder of the relation between the intervention and operative outcomes, uterine weight was significantly positively correlated with operative charges and time (P < 0.05), whereas physician endoscopic experience was significantly negatively related to both (P < 0.05). We observed a 19-minute, statistically significant decrease in adjusted mean operative time but no difference in total or equipment charges. Discussion Our study of quality improvement demonstrates an improvement in LAVH operating times related to surgeon bench-marking, without a decrease in operating charges. Previous research has shown that quality management decreases surgical procedure time in general surgery and ophthalmology ophthalmology (ŏf'thălmŏl`əjē), branch of medicine specializing in the anatomy, function and diseases of the eye. Ophthalmologists specialize in the medical and surgical treatment of eye disorders, vision measurements for ; we did not identify any previous studies of its impact on gynecologic surgery in a MEDLINE The online medical database of the U.S. National Library of Medicine (NLM) whose parent is the National Institutes of Health, Bethesda, MD. MEDLINE contains millions of articles from thousands of medical journals and publications. The consumer section of the site (http://medlineplus. search. How benchmarking influences physician behavior is undoubtedly complex, but perhaps physicians are self-motivated to improve when presented with comparative data, without need for punitive action. (8) We observed a stable finding of improved operative times even after additional factors accounting for case mix and physician experience were considered. In addition, a sensitivity analysis of cases restricted to physicians contributing cases both before and after the intervention provides confirmatory evidence; the decreased operative times in this group approached significance, a difference probably due to a dilution of statistical power from a 45% decrease in sample size. Although it is difficult to quantify the degree of clinical benefit of a 19-minute average decrease in operating time, prolonged operating time in lithotomy position lithotomy position n. A supine position in which the hips and knees are fully flexed with the legs spread apart and raised and the feet resting in straps. Also called dorsosacral position. , particularly beyond 2 hours, increases the risk of lower extremity lower extremity n. The hip, thigh, leg, ankle, or foot. Also called inferior limb, pelvic limb. neuropathy. (11) In addition, prolonged anesthesia duration may contribute to development of pulmonary complications. (12) In the setting of a residency training program, where the educational mission often prolongs operating times, this time savings has clear utility. In retrospect. addressing equipment charges was unlikely to have markedly affected total LAVH operating charges, as roughly 75% of our charges are facility charges. The observed increase in facility charges is not easy to explain, given the number of factors influencing such a global category. Unmeasured variables such as increased compensation for surgical ancillary staff or adjustments in physical plant expenditures may bear partial responsibility. Future quality improvement studies of procedures should consider including additional factors in the analysis. The failure of equipment charges to decrease is enigmatic, as our initiative actively discouraged unnecessary use of disposable equipment. Review of operative reports suggests most cases used standard reusable endoscopic equipment. However, more than 95% of the postintervention surgeries used a disposable cutting forceps (Gyrus gyrus /gy·rus/ (ji´rus) pl. gy´ri [L.] cerebral g. angular gyrus one arching over the superior temporal sulcus, continuous with the middle temporal gyrus. Medical, Maple Grove Maple Grove might designate:
Cutting instrument or tool consisting of a pair of opposed metal blades that meet and cut when the handles at their ends are brought together. Modern scissors are of two types: the more usual pivoted blades have a rivet or screw connection between the cutting ends . Cost containment by restricting the use of disposable equipment would only be effective if the equipment did not contribute to savings from total operating time used. A previous criticism of our institution should be addressed: A number of previous LAVH studies suggest shorter operating times and decreased cost compared with our reported figures. (13) Training of gynecology residents probably contributes to prolonged operating times, as in all cases a senior resident performs half of the procedure. In contrast, other studies often report the experience of a single surgeon or small team of surgeons with significant surgical volume. With the exception of a small handful of our staff the vast majority of our physicians do not have formal subspecialty subspecialty, n a limited portion of a narrowly defined professional discipline. E.g., surgery is a specialty of medicine and pediatric vascular surgery is a subspecialty. training in advanced endoscopic surgery. An additional confounder to consider in future studies might also include physician experience with vaginal surgery, although quantifying this skill may be difficult. Another limitation of this study is, of course, that it represents a single institution's experience. There may be significant differences in the way total vaginal hysterectomy and LAVH are performed at other institutions that report shorter operating times. (2.5) A study from Dorsey and colleagues (3) describes the experience of approximately 100 surgeons at Greater Baltimore Medical Center Greater Baltimore Medical Center, known to many as simply as GBMC, is a hospital located in the Baltimore suburb of Towson, Maryland. Its entrance is on Charles Street, about 1½ miles south of Baltimore Beltway exit 25, and just one block south of Towsontown Boulevard. during the period of 1993 to 1994. Their procedure time is comparable, 158 minutes on average, with a mean cost of $6,116, which, when adjusted for inflation and the typical 2- to 3-fold conversion for hospital charges, approaches $11.000 in 2001 dollars. Nevertheless, our results resemble the community standard reported in data from the Metropolitan Insurance Companies ($14,500 in 1998). (14) Furthermore, by drawing data from individual chart review, the present study represents a pure population of uncomplicated LAVHs--large databases may erroneously code procedures that were actually diagnostic laparoscopy or total abdominal hysterectomy to·tal abdominal hysterectomy n. Abbr. TAH An abdominal hysterectomy in which the uterus and cervix are removed. total abdominal hysterectomy , which would underestimate the true cost of LAVH. This study design lacked a formal measure to quantify physician attitudes toward cost and time efficiency pre- and postintervention, although other nonphysician factors influence performance of endoscopic surgery at Prentice Women's Hospital. Education and participation of residents and operating room staff are obviously important in any quality improvement effort. Anecdotally, our attending gynecologists demonstrated a clear awareness of the study, with a mixed reception of its suggestions. Future studies should include a survey to characterize the attitudes of attending surgeons toward efficiency. Conclusion The final decision on the appropriateness of LAVH or other minimally invasive approaches to hysterectomy in modern gynecologic practice will depend on the willingness of physicians to optimize their individual performance of this procedure. The emergence of alternative approaches to treatment of uterine disorders should be further stimulus for this optimization. Institutions can preempt pre·empt or pre-empt v. pre·empt·ed, pre·empt·ing, pre·empts v.tr. 1. To appropriate, seize, or take for oneself before others. See Synonyms at appropriate. 2. a. the criticism leveled at the performance of such advanced endoscopic procedures by monitoring their respective outcomes as part of ongoing improvements in surgical performance. The same techniques and principles have potential widespread value across the entire field of women's health Women's Health Definition Women's health is the effect of gender on disease and health that encompasses a broad range of biological and psychosocial issues. . (7) Acknowledgments The authors gratefully acknowledge the assistance of Katherine E. Hartmann, MD, PhD, in developing the final form of this manuscript. References 1. Kovac RS. Guidelines to determine the role of laparoscopically assisted vaginal hysterectomy. Am J Obstet Gynecol 1998;178:1257-1263. 2. Figueiredo O, Figueiredo EG, Figueiredo PG, et al. Vaginal removal of the benign nonprolapsed uterus: experience with 300 consecutive operations. Obstet Gynecol 1999;94:348-351. 3. Dorsey JH, Holtz PM, Griffiths RI, et al. Costs and charges associated with three alternative techniques of hysterectomy. N Engl J Med 1996;335:476-482. 4. Kovac SR. Hysterectomy outcomes in patients with similar indications. Obstet Gvnecol 2000;95:787-793. 5. Summitt Jr, RL Stovall, TG, Lipscomb GH, et al. Randomized ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol 1992;80:895-901. 6. Munro MG, Reiter RC, Gambone JC. Technology assessment in women's health care. Clin Obstet Gynecol 1994;37:180-191. 7. Morris M, Gambone JC. Making continual improvements to health care. Clin Obstet Gynecol 1994;37:137-148. 8. Megler DD, Senn GF. Benchmarking: the key to influencing physicians. Phys Exec 1999:50-55. 9. Milad MP, Lindau ST. A comprehensive resident training program in operative endoscopy. Obstet Gynecol 1998;92:148-152. 10. US Department of Labor. Consumer Price Index: All Urban Consumers. Available at: http://data.bls.gov/cgi-bin/surveymost. Accessed May 26, 2002. 11. Warner MA, Warner DO, Harper CM, et al. Lower extremity neuropathies associated with lithotomy positions. Anesthesiology anesthesiology (ăn'ĭsthē'zēŏl`əjē), branch of medicine concerned primarily with procedures for rendering patients insensitive to pain, and for supporting life systems under the strains of anesthesia and surgery. 2000;93:938-942. 12. Mitchell CK, Smoger SH, Pfeifer MP, et al. Multivariate analysis multivariate analysis, n a statistical approach used to evaluate multiple variables. multivariate analysis, n a set of techniques used when variation in several variables has to be studied simultaneously. of factors associated with postoperative pulmonary complications following general elective surgery elective surgery Surgery Any operation that can be performed with advanced planning–eg, cholecystectomy, hernia repair, colonic resection, coronary artery bypass . Arch Surg 1998;133:194-198. 13. Boike GM, Elfstrand EP, DelPriore G, et al. Laparoscopically assisted vaginal hysterectomy in a university hospital: report of 82 cases in comparison with abdominal and vaginal hysterectomy. Am J Obstet Gynecol 1993;168:1690-1701. 14. Mushinski M. Average charges for three types of hysterectomy procedures: United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , 1998. Stat Bull--Metropolitan Ins Comp 2000;81:27-36. Life shrinks or expands in proportion to one's courage. --Anais Nin Frank F. Tu, MD, MPH, Joe Feinglass, PHD, and Magdy P. Milad, MD, MS From the Department of Obstetrics and Gynecology obstetrics and gynecology Medical and surgical specialty concerned with the management of pregnancy and childbirth and with the health of the female reproductive system. and the Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL. Reprint requests to Dr. Frank F. Tu, 2650 Ridge Avenue, Walgreen's Building, Suite 1507, Evanston, IL. Email: ftu@enh.org Accepted April 18, 2005. RELATED ARTICLE: Key Points * Operating time decreased after implementation of a quality improvement initiative for laparoscopically assisted vaginal hysterectomy. * Operating costs operating costs npl → gastos mpl operacionales , adjusted for inflation, did not change after implementation of a quality improvement initiative for laparoscopically assisted vaginal hysterectomy. * Use of disposable surgical equipment must be balanced against savings in operating room costs to achieve optimal efficiency.
Table 1. Profile of Prentice Women's Hospital LAVH Study Cohort (1996
to 2001)
Case characteristics n1/n2 Preintervention
Age (y) 167/47 45.4 [+ or -] 7.6
Surgeon experience (laparoscopic cases/yr) 167/47 63.7 [+ or -] 47.3
Uterine weight (g) 148/47 175.2 [+ or -] 84.1
Previous history of vaginal delivery 166/47 63%
Previous cesarean section 166/47 8%
Case characteristics Postintervention P
Age (y) 46.2 [+ or -] 8 NS
Surgeon experience (laparoscopic cases/yr) 47.2 [+ or -] 35.6 0.03
Uterine weight (g) 148.4 [+ or -] 64.6 0.05
Previous history of vaginal delivery 60% NS
Previous cesarean section 11% NS
Values are mean [+ or -] SD or proportions.
NS, P > 0.05
n1 = 1996-2000; n2 = 2000-2001.
Table 2. Distribution of diagnoses and pathologic findings for Prentice
Women's Hospital LAVH Study Cohort
Preintervention Postintervention P
Diagnoses n = 167 n = 47
Symptomatic 84 (50%) 22 (47%) NS
leiomyomata
Menorrhagia 65 (39%) 24 (51%) NS
Chronic pelvic pain 30 (18%) 4 (9%) NS
Dysmenorrhea 25 (15%) 5 (11%) NS
Endometriosis 11 (7%) 1 (2%) NS
Endometrial 11 (7%) 6 (13%) NS
hyperplasia
Adnexal disease 11 (7%) 8 (17%) 0.02
Cervical dysplasia 8 (5%) 2 (4%) NS
Pathological findings n = 166 n = 47
Leiomyomata 111 (67%) 30 (64%) NS
Adenomyosis 62 (37%) 15 (32%) NS
Pelvic adhesion 36 (22%) 10 (21%) NS
Adnexal cyst 14 (8%) 8 (17%) NS
Endometrial polyp 12 (7%) 6 (13%) NS
Endometrial 8 (5%) 4 (9%) NS
hyperplasia
Cervical dysplasia 6 (4%) 1 (2%) NS
Endometriosis 3 (2%) 5 (11%) 0.005
More than one preoperative diagnosis or pathological finding was
possible.
NS, P > 0.05.
Table 3. Operating time and charges among Prentice Women's Hospital LAVH
Study Cohort before and after benchmarking
Preintervention Postintervention P
OR time (a) (min) 197 (190, 205) 182 (168, 195) 0.05
Charges (b) ($)
Total 11,051 (10,820, 11,626 (10,876, NS
11,389) 12,178)
Facility 7,883 (7,537, 8,183) 8,087 (7,782, 8,776) 0.04
Nursing 1,814 (1,814, 1,851) 1,987 (1,987, 1,990) 0.0001
Equipment 1,624 (1,452, 1,723) 1,719 (1,623, 1,825) NS
Lab 586 (540, 615) 601 (416, 704) NS
Pharmacy 676 (659, 705) 615 (569, 704) NS
Other 86 (0, 115) 17 (0, 136) NS
(a) Mean, 95% CI.
(b) Median, 95% CI, adjusted for Consumer Price Index.
NS, P > 0.05.
Table 4. Adjusted mean operating times, total charges, and equipment
charges for Prentice Women's Hospital LAVH Study Cohort
n P
Mean operating times (a)
Before 148 198 min 0.01
After 47 179 min
Total charges
Before 148 $11,489 NS
After 47 $12,103
Equipment charges
Before 124 $1,658 NS
After 47 $1,743
(a) Operating time and total charges adjusted for physician experience
and uterine weight; equipment charges are adjusted for uterine weight
only.
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