Physician procedure volume and related adverse events after surgically induced abortion: a population-based cohort study

Liu, Ning; Vigod, Simone N.; Farrugia, Michele; Urquía, Marcelo L.; Ray, Joel G.

doi:10.1503/cmaj.181288

Cited by 9 publications

(8 citation statements)

References 31 publications

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“…Compared with averaging the number of procedures performed over the study years, this definition ensured that surgeon volume could dynamically change in response to yearto-year variation of hysterectomy. 36,37…”

Section: What Does This Add To What Is Known?mentioning

confidence: 99%

Practice variation in bilateral salpingo-oophorectomy at benign abdominal hysterectomy: a population-based study

Cusimano

Moineddin

Chiu

et al. 2021

American Journal of Obstetrics and Gynecology

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BACKGROUND: Bilateral salpingo-oophorectomy at benign hysterectomy is not recommended in premenopausal women who are in the premenopausal stage because of its potential associations with increased all-cause mortality and cardiovascular disease; however, contemporary practice patterns are unknown. OBJECTIVE: This study aimed to quantify between-surgeon variation in bilateral salpingo-oophorectomy and identify surgeon and patient characteristics associated with bilateral salpingo-oophorectomy to evaluate current quality of care and identify targets for knowledge translation and future research. STUDY DESIGN: We conducted a population-based retrospective cross-sectional study of adult women (!20 years) undergoing benign abdominal hysterectomy from 2014 to 2018 in Ontario, Canada. Hierarchical multivariable logistic regression models, stratified by age group (<45, 45e54, !55 years), were used to model between-surgeon variation after multivariable adjustment for patient and surgeon characteristics. Cases of bilateral salpingo-oophorectomy were classified as potentially appropriate or potentially avoidable based on the presence or absence of diagnostic indications. RESULTS: Of 44,549 eligible women, 17,797 (39.9%) underwent concurrent bilateral salpingo-oophorectomy, and 26,752 (60.1%) did not.In all three age strata, the individual surgeon providing care was one of the strongest factors influencing whether patients received bilateral salpingooophorectomy (median odds ratio, 2.00e2.53). Surgeons accounted for more than 22% of the residual observed variation in bilateral salpingooophorectomy in women aged 45e54 years compared with 16% and 14% of the residual observed variation in bilateral salpingo-oophorectomy in women aged <45 and !55 years, respectively. Non-gynecologic patient factors, such as obesity (odds ratio, 1.33; 95% confidence interval, 1.17e1.52; P<.001) and residing in low-income regions (odds ratio, 1.34; 95% confidence interval, 1.16e1.55; P<.001), were also associated with bilateral salpingo-oophorectomy. Approximately 40% of patients who underwent bilateral salpingo-oophorectomy had no indication for the procedure in their discharge records. CONCLUSION: Marked between-surgeon variation in bilateral salpingo-oophorectomy rates, even after adjusting for patient case mix, suggests ongoing uncertainty in practice. Stronger evidence-based guidelines on the risks and benefits of salpingo-oophorectomy as women age are needed, particularly focusing on perimenopausal women.

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Section: What Does This Add To What Is Known?mentioning

confidence: 99%

Practice variation in bilateral salpingo-oophorectomy at benign abdominal hysterectomy: a population-based study

Cusimano

Moineddin

Chiu

et al. 2021

American Journal of Obstetrics and Gynecology

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“…This com prises both adverse events and morbidities related to pregnancy and abortion, including those unlikely to be related to the care provided or the techniques of the procedure (for example, the authors retained all deaths while acknowledging that most deaths were due to assault or suicide); they reported 28 deaths in their population of 529 141, a rate of 5.3 allcause deaths per 100 000 abortions. 1 In contrast, the US Centers for Disease Control and Prevention meticulously defined specific abortionrelated mortality 9 and recently reported that "The national legal induced abortion casefatality rate for 2008-2014 was 0.62 legal induced abortionrelated deaths per 100 000 reported legal abortions." 9 Furthermore, the authors of the linked research did not include diagnostic codes specific to abortion procedures (International Statistical Classification of Diseases and Related Health Problems, 10th Revision code O08) in their outcome.…”

Section: Key Pointsmentioning

confidence: 99%

“…The authors of the linked research concluded that their find ings support centralization of abortion services within special ized abortion clinics staffed by highvolume providers. 1 However, choosing between a high versus lowvolume provider may not be realistic for many patients in rural locations. In these settings, a surgical abortion by a lowvolume provider (which may already require substantial travel) may be the most expeditious, and thus safest, option.…”

Section: Key Pointsmentioning

confidence: 99%

“…I n linked research, Liu and colleagues 1 analyzed Ontario administrative health data to investigate the safety of sur gical abortion. Their meticulous analysis found that, in Ontario, surgical abortions were highly safe with very rare severe adverse events -1.6 per 1000 abortions (95% confidence inter val [CI] 1.5-1.7).…”

mentioning

confidence: 99%

“…The authors found small absolute increases in the rate of uncommon severe adverse events in the lower volume group, 3.7 per 1000 abortions (95% CI 3.2-4.2) compared with 1.4 per 1000 abortions (95% CI 1.3-1.5) among highvolume providers. 1 A patient with an abnormal or unintended pregnancy may choose only between abortion and birth. The small absolute risk differences comparing abortion providers by volume must be interpreted in the context of these limited choices.…”

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confidence: 99%

See 2 more Smart Citations

Abortion services in Canada: access and safety

Schummers

Norman

2019

CMAJ

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Impact of surgical approach on oncologic outcomes in women undergoing radical hysterectomy for cervical cancer

Cusimano

Baxter

Gien

et al. 2019

American Journal of Obstetrics and Gynecology

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111

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BACKGROUND: Recent studies demonstrating shorter survival among cervical cancer patients undergoing minimally invasive versus open radical hysterectomy could not account for surgeon volume and require confirmation in other jurisdictions with larger sample sizes, longer follow-up, and data on disease recurrence. OBJECTIVE: To determine if surgical approach is associated with oncologic outcomes in cervical cancer patients undergoing minimally invasive or open radical hysterectomy, while accounting for mechanistic factors including surgeon volume. STUDY DESIGN: We performed a population-based retrospective cohort study of cervical cancer patients undergoing primary radical hysterectomy by a gynecologic oncologist from 2006 to 2017 in Ontario, Canada. A multivariable marginal Cox proportional hazards model and cause-specific hazards model were used to evaluate the association of surgical approach with all-cause death and recurrence respectively, clustering at the surgeon level. We tested for interactions between surgical approach and either pathologic stage or surgeon volume. RESULTS: We identified 958 patients (minimally invasive 475; open 483) with mean age 45.9 and a median follow-up of 6 years. Of minimally invasive procedures, 89.6% were performed laparoscopically and 10.4% robotically. The unadjusted 5-year cumulative incidences of all-cause death (minimally invasive 12.5%; open 5.4%), cervical cancer death (minimally invasive 9.3%; open 3.3%), and recurrence (minimally invasive 16.2%; open 8.4%) were significantly increased for minimally invasive radical hysterectomy in patients with stage IB disease, but not the cohort overall. After adjusting for patient factors and surgeon volume, minimally invasive radical hysterectomy was associated with increased rates of death (hazard ratio [HR], 2.20; 95% confidence interval [CI], 1.15e4.19) and recurrence (HR, 1.97; 95% CI, 1.10e3.50) compared to open radical hysterectomy in patients with stage IB disease (n ¼ 534), but not IA disease (n ¼ 244; HR, 0.73; 95% CI, 0.13e4.01; HR, 0.34; 95% CI, 0.10e1.10). CONCLUSION: Minimally invasive radical hysterectomy is associated with increased rates of death and recurrence in patients with stage IB cervical cancer even after controlling for surgeon volume; open radical hysterectomy should be the recommended approach in this population.Although there may be a subset of patients with microscopic early-stage disease for whom minimally invasive radical hysterectomy remains safe, additional studies are required.

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Physician procedure volume and related adverse events after surgically induced abortion: a population-based cohort study

Cited by 9 publications

References 31 publications

Practice variation in bilateral salpingo-oophorectomy at benign abdominal hysterectomy: a population-based study

Practice variation in bilateral salpingo-oophorectomy at benign abdominal hysterectomy: a population-based study

Abortion services in Canada: access and safety

Impact of surgical approach on oncologic outcomes in women undergoing radical hysterectomy for cervical cancer

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