International Journal of Gynecology & Obstetrics 71 Ž2000.

159᎐169

Special article

Decision-directed hysterectomy: a possible approach to

improve medical and economic outcomes

S.R. KovacU
Department of Gynecology and Obstetrics, Emory Uni¨ ersity School of Medicine, Atlanta, GA, USA

Received 15 January 2000; received in revised form 7 June 2000; accepted 19 June 2000

Abstract

Objecti¨ e: This study was undertaken to determine if the use of formal guidelines in selecting the route of
hysterectomy would improve medical and economic outcomes. Method: Data from 4595 hysterectomies performed at
a single center in women whose primary diagnosis were unrelated to invasive cancer or pregnancy were analyzed in
terms of mean, uterine weight, costs, length of stay, and complications. Results: When formal guidelines were used to
determine the route of hysterectomy, vaginal hysterectomy was performed in 90% of the patients treated and in
100% of the patients in whom the pathology was confined to the uterus. In comparison, when formal guidelines were
not incorporated in the decision-making process, vaginal hysterectomy was performed in 42% of the patients treated
and in 64% of the patients in whom the pathology was confined to the uterus. Conclusions: Using these or similar
guidelines to assist in clinical decision making would have resulted in a potential savings of US$1 184 000 for every
1000 hysterectomies performed at the institution where this study was undertaken and would have freed up 1020
patient-bed days and reduced complications by approximately 20%. 䊚 2000 International Federation of Gynecology
and Obstetrics All rights reserved.

Keywords: Abdominal hysterectomy, AH; Decision making; Economics; Hysterectomy; Laparoscopically assisted vaginal hysterec-
tomy; LAVH; Vaginal hysterectomy, VH

U Department of Gynecology and Obstetrics, Emory University School of Medicine, 69 Butler Street S.E., Atlanta, GA 30303,
USA. Tel.: q1-404-616-3540; fax: q1-404-521-3589.
E-mail address: pelvicsurg@aol.com ŽS.R. Kovac..

0020-7292r00r$20.00 䊚 2000 International Federation of Gynecology and Obstetrics All rights reserved.
PII: S 0 0 2 0 - 7 2 9 2 Ž 0 0 . 0 0 3 1 6 - 7
160 S.R. Ko¨ ac r International Journal of Gynecology & Obstetrics 71 (2000) 159᎐169
1. Introduction
The delivery of health services for hysterec-
tomy varies markedly from community-to-com-
munity and physician-to-physician. For the past
19 years, abdominal hysterectomy has been the
preferred method of hysterectomy for gynecologic
surgeons. During this time 7 557 285 abdominal
hysterectomies were performed compared with
2 934 252 vaginal hysterectomies at a rate of 2.06:1
w1x. Does this variation represent a consensus that
abdominal hysterectomy offers the greatest bene-
fits to the patient group in which it was per-
formed or does it reflect a difference in physician
practice styles?
An abundance of well-documented articles
show that the abdominal approach is associated
with a higher incidence of complications w2᎐4x,
more adverse post-operative quality-of-life out-
comes w5x, longer length of stay and convalescence
w3,4x and higher hospital charges as compared
with the vaginal approach w3,4x. Despite the over-
whelming evidence in favor of vaginal hysterec-
tomy, no formal guidelines have been adopted to
assist physicians in selecting the most clinically
appropriate route of hysterectomy. In the absence
of such practice guidelines to help identify the
appropriateness of a particular route of hysterec-
tomy, gynecologic surgeons continue to perform
abdominal and vaginal hysterectomy for similar
indications.
Although some gynecologists, professional soci-
eties, government agencies, and managed care
organizations acknowledge that abdominal hys-
terectomy is the preferred route for more serious
pathologic conditions, it has been shown that
physicians do not always select the abdominal
route based on the severity of the patient’s condi-
tion w6x. In order to study the surgical outcomes
of the routes of hysterectomy for each indication,
we must first be able to assess the severity of
pathologic conditions.
Specific guidelines incorporating uterine size,
risk factors, and uterine and adnexal mobility and
accessibility have been shown to be useful in
helping physicians select the operative route of
hysterectomy based on the severity of the patho-
logic condition. When physicians used these
guidelines, they were successful in reducing the
number of abdominal hysterectomies performed
w3x. Further development of these guidelines into
a decision tree provides an opportunity to test the
validity of this decision-making process.
The objective of this study was to determine
the medical and economic outcomes of applying
formal practice guidelines that confirm, in-
traoperatively if necessary, the severity of the
patient’s pathologic condition ŽFig. 1.. Thus,
rather than presuming that particular route of
hysterectomy is contraindicated, the surgeon is
required to document the accuracy of the diag-
noses with each step of the decision tree in order
to prevent a diagnosisrtreatment discrepancy and
select the most appropriate surgical route.
2. Materials and methods
Data were collected for every consecutive hys-
terectomy at St. John’s Mercy Medical Center in
St. Louis between 1988 and 1993. The medical
records department at the hospital transcribed
the following information from the medical charts:
䢇 patient’s diagnosis and pelvic pathology;
䢇 route of hysterectomy;
䢇 uterine weight Žfrom the pathology record, if
the uterine weight was not recorded, the case
was excluded from analysis .;
䢇 complications Žfrom the face sheet of the med-
ical record.;
䢇 hospital charges;
䢇 length of stay;
䢇 age;
䢇 parity;
䢇 race; and
䢇 type of insurance Ždefined as private, managed
care, Medicare, Medicaid, or self-pay..
Length of stay was the number of days from
admission to discharge. Charges were the actual
amounts the hospital charged the patient or in-
surer. Pelvic pathology and surgical procedures
were coded using ICD-9 codes and CPT-4 surgi-
cal codes, respectively. The laparoscopically as-
sisted vaginal hysterectomy category included any
 S.R. Ko¨ ac r International Journal of Gynecology & Obstetrics 71 (2000) 159᎐169 161

Fig. 1. Selecting the route of hysterectomy.

procedure involving laparoscopy, including total cians in the study and coded by medical record
laparoscopic hysterectomy. personnel according to ICD-9 codes. Complica-
Complications were identified on the face sheet tions were then grouped into the following seven
of the medical record by each of the 126 physi- categories using ICD-9 codes:
162 S.R. Ko¨ ac r International Journal of Gynecology & Obstetrics 71 (2000) 159᎐169
䢇 hemorrhage;
䢇 acute myocardial infarction;
䢇 post-operative fever or infection;
䢇 intestinal obstruction;
䢇 urinary complications;
䢇 injury to bladder or ureter; and
䢇 accidental perforation of a blood vessel, nerve,
or organ.
The study group was composed of women who
underwent a decision-directed hysterectomy
ŽDDH physician group, n s 2., in which the route
of hysterectomy was determined according to the
guidelines shown in Fig. 1. The comparison group
Žnon-DDH physician group, n s 124. was com-
posed of women whose gynecologic surgeons did
not use the guidelines in Fig. 1, but instead used a
personal, informal, decision-making process to
determine the hysterectomy route for their
patients.
3. Statistical methods and analysis plan
Cases were classified by uterine weight Ž- 280
or G 280 g., diagnostic type ŽI or II., decision
process ŽDDH or non-DDH., and surgical proce-
dure wabdominal hysterectomy ŽAH., laparoscopi-
cally assisted vaginal hysterectomy ŽLAVH., or
vaginal hysterectomy ŽVH.x. Diagnostic Type I
includes patients with pathology confined to the
uterus. Type II patients included those with
pathology suspected to extend beyond the con-
fines of the uterus.
Analysis of variance ŽANOVA. was applied to
uterine weight, charges, and length of stay ŽLOS.
using the SAS䊛 ŽSAS Statistical Software, SAS
Institute Inc., SAS Campus, Campus Drive, Cary,
NC 27513, USA. procedure GLM w7x Complica-
tions were identified and grouped into seven cate-
gories. An additional eighth complication cate-
gory was created to indicate for each case whether
any of the seven categories were present. The
SAS䊛 procedure MULTTEST was used to form
simultaneous comparisons of the eight complica-
tion rates. The bootstrap option was used to
control the experiment-wise error. Using the
bootstrap technique, the database was resampled
100 000 times; in each cycle, either Fisher’s exact
test or the Cochran-Armitage test for trends was
computed and compared with the value obtained
from the original data set w8,9x. The results were
then confirmed by repeating the process with
another random number seed. Test statistics were
declared statistically significant if the resulting P
value was less than 0.05.
The intent of the analyses was to compare
outcomes for DDH patients with identical groups
of non-DDH patients. The rationale was that if
differences occurred between like groups, they
must have been caused by differences in the
surgical decision-making process. Because all hys-
terectomies were performed at one institution,
policies regarding charges and LOS affected all
patients equally. Thus, differences in outcomes
between a group of DDH cases and the corre-
sponding group of non-DDH cases must be at-
tributed to differences in the decision process
leading up to the selection of the route of hys-
terectomy.
4. Results
After excluding patients whose primary diag-
noses were related to invasive cancer or preg-
nancy, patients with ambiguous ICD-9 procedure
codes, patients with unrecorded uterine weight,
and patients in whom pelvic pathology was not an
indication, 4595 cases remained.
Type I patients Ž n s 3177. displayed conditions
confined to the uterus, including leiomyomata,
adenomyosis, bleeding, prolapse, carcinoma in situ
of the cervix, or cervical intraepithelial neoplasia.
Type II patients Ž n s 1418. had at least one
pathological condition that was thought to extend
beyond the confines of the uterus, including con-
ditions such as endometriosis, pelvic adhesive dis-
ease, adnexal pathology, chronic pelvic pain, and
chronic pelvic inflammatory disease and, in most
cases, at least one Type I indication. Those with
low uterine weights Ž8᎐279 g. Ž n s 4086. repre-
sented 89% of all cases; the remaining 509
patients displayed uterine weights of 280 g or
more.
 S.R. Ko¨ ac r International Journal of Gynecology & Obstetrics 71 (2000) 159᎐169
Fig. 2. Ža. Diagnostic profile when uterus - 280 g. Cases with diagnosis Ž%.. Žb. Diagnostic profile when uterus G 280 g. Cases with diagnosis Ž%..

163
164 S.R. Ko¨ ac r International Journal of Gynecology & Obstetrics 71 (2000) 159᎐169

Fig. 2. Ž Continued..
 S.R. Ko¨ ac r International Journal of Gynecology & Obstetrics 71 (2000) 159᎐169
Fig. 2a,b represent detailed diagnostic profiles
of the study population. Overall diagnostic pro-
files between the DDH patients and non-DDH
patients were similar. Prolapse, bleeding, fibroids,
and adenomyosis were the most prevalent diag-
noses.
To assess the medical and economic benefits of
applying guidelines to determine the surgical ap-
proach, the outcomes of the 675 hysterectomies
in the DDH group were compared with the out-
comes of the remaining 3920 hysterectomies in
the non-DDH group. Table 1 shows mean uterine
weights, mean charges, and mean length of stay
ŽLOS.. Compared with the non-DDH group, the
DDH group had a significantly higher percentage
of Type I patients in both weight groups. In the
low-uterine-weight group, the mean uterine
weight of the DDH group was 13.3 g less than the
weight of the non-DDH patients. Although this
was a statistically significant difference Ž Ps 0.003,
ANOVA, Type III F-test., it was not surgically
significant. In the high-uterine-weight group, the
mean uterine weight of the DDH patients was
slightly larger than non-DDH cases, although the
difference was not statistically significant.
The charge comparison reveals that the mean
charges of the DDH group were significantly less
than the mean charges of non-DDH cases, re-
gardless of patient type or uterine weight. Among
low-uterine-weight Type I patients, the mean
charge was lower for DDH patients compared
with the others, resulting in a statistically signifi-
cant Ž P- 0.001. per-case savings of US$1219.
Table 1
Number of cases, mean uterus weight, mean charges, and mean LOS
Uterus Type DDH group
size N Uterus weight Charges
Žg. ŽUS$.
Uterus Ia 559 114.82 4343
- 280 g IIb 65 107.74 4990
Uterus Ia 50 488.72 4719
G 280 g IIb 1 636.00 5372
a
Type I patients displayed pathology confined to the uterus.
b
Type II patients displayed pathology extending beyond the confines of the uterus and, in most cases, Type I conditions. Normal
weight of the uterus is 70᎐125 g.
165
Among the low-uterine-weight Type II patients,
the mean charge was lower for the DDH patients
compared with the others, resulting in a statisti-
cally significant Ž P- 0.001. per-case savings of
US$1455. Among the high-uterine-weight cases,
the difference in charges for Type I patients was
also statistically significant Ž Ps 0.001. ŽTable 1..
The application of formal practice guidelines
resulted in reduced length of stay. For Type I
cases in both weight groups, DDH patients re-
quired 0.92᎐1.43 fewer days Ž P- 0.003, Bonferr-
oni bound..
Table 2 compares the mean charges and mean
LOS stay for the three types of hysterectomy.
Regardless of uterine weight, none of the sur-
geons in either group chose VH as the primary
surgical decision before laparotomy or laparo-
scopy when they suspected the patient’s condition
extended beyond the confines of the uterus. In
the DDH group, all 609 Type I patients under-
went VH without laparoscopy, regardless of uter-
ine weight. In comparison, among Type I patients
in the non-DDH group, 1647 Ž64%. women un-
derwent vaginal hysterectomies, 833 Ž32%. under-
went abdominal hysterectomies and 88 Ž3%. un-
derwent LAVH. Among Type II, low-uterine-
weight patients in the DDH group, 61 Ž96%.
underwent laparoscopy to determine the severity
of their condition before uterine removal, result-
ing in reduced charges and LOS when compared
with the non-DDH group. In addition, in 4% of
the Type II DDH patients in the low-uterine-
weight group, the laparoscope was not indicated
Non-DDH group
LOS N Uterus weight Charges LOS
Ždays. Žg. ŽUS$. Ždays.
2.53 2270 122.42 5562 3.44
2.83 1192 126.39 6445 3.90
2.26 298 470.95 6068 3.69
4.00 160 490.21 6459 3.90
166 S.R. Ko¨ ac r International Journal of Gynecology & Obstetrics 71 (2000) 159᎐169

Table 2
Number of cases, mean charges, and mean LOS for each procedurea

Uterus Type AH LAVH VH

size N Charges LOS N Charges LOS N Charges LOS
ŽUS$. Ždays. ŽUS$. Ždays. ŽUS$. Ždays.

DDH group
Uterus Ib 0 ᎐ ᎐ 0 ᎐ ᎐ 559 4343 2.53
- 280 g IIc 4 6098 3.75 61 4917 2.77 0 ᎐ ᎐
Uterus Ib 0 ᎐ ᎐ 0 ᎐ ᎐ 50 4719 2.26
G 280 g IIc 1 5372 4.00 0 ᎐ ᎐ 0 ᎐ ᎐

Non-DDH group
Uterus Ib 609 6230 4.10 78 7500 2.63 1583 5209 3.23
- 280 g IIc 964 6390 4.13 228 6679 2.92 0 ᎐ ᎐
Uterus Ib 224 6052 3.94 10 8774 2.70 64 5701 2.98
G 280 g IIc 157 6422 3.92 3 8394 3.00 0 ᎐ ᎐
a
Abbre¨ iations: AH, abdominal hysterectomy; LAVH, laparoscopically assisted vaginal hysterectomy; VH, vaginal hysterectomy.
b
Type I patients displayed pathology confined to the uterus.
c
Type II patients displayed pathology extending beyond the confines of the uterus and, in most cases, Type I conditions.

because the patients exhibited vaginal inaccessi-
bility, which dictated an abdominal hysterectomy.
In comparison, among Type II, low-uterine-weight
patients in the non-DDH group, 228 Ž19%. women
underwent laparoscopy before uterine removal.
Among Type I, low-uterine weight patients in the
non-DDH group, 78 Ž3%. diagnostic laparo-
scopies were performed at a mean charge of
US$7500.
As shown in Table 3, among the 61 LAVH
Type II cases in the low-uterine-weight DDH
group, 57 Ž93%. procedures were completed via
the vaginal route following diagnostic laparo-
scopy. In comparison, among Type II patients in
the low-uterine-weight, non-DDH group, 81 Ž36%.
of 228 LAVH procedures were completed through
the abdominal route and 147 Ž64%. were com-
pleted vaginally.

Table 3
Number of cases, mean charges, and mean LOS when laparoscopy was used a

Uterus Type Surgery DDH group Non-DDH group

size N Charges LOS N Charges LOS
ŽUS$. Ždays. ŽUS$. Ždays.

Uterus Ib LªA 0 ᎐ ᎐ 8 6841 3.75

- 280 g LªV 0 ᎐ ᎐ 70 7575 2.50
IIc LªA 4 9655 5.50 81 6465 3.94
LªV 57 4585 2.58 147 6798 2.36
Uterus Ib LªA 0 ᎐ ᎐ 0 ᎐ ᎐
G 280 g LªV 0 ᎐ ᎐ 10 8774 2.70
IIc LªA 0 ᎐ ᎐ 1 6448 3.00
LªV 0 ᎐ ᎐ 2 9367 3.00
a
Abbre¨ iations: L ª A represents a hysterectomy that includes laparoscopy to confirm the diagnosis and, consequently, the need
to complete the surgery via the abdominal route. L ª V represents a hysterectomy that includes laparoscopy to confirm the
diagnosis and, consequently, the ability to complete the surgery via the vaginal route.
b
Type I patients displayed pathology confined to the uterus.
c
Type II patients displayed pathology extending beyond the confines of the uterus and, in most cases, Type I conditions.
 S.R. Ko¨ ac r International Journal of Gynecology & Obstetrics 71 (2000) 159᎐169 167

Table 4
Complications Ž% of cases. a

Complication DDH group Non-DDH group

AH LªA LªV VH AH LªA LªV VH
Ns5 Ns4 N s 57 N s 609 N s 1954 N s 90 N s 229 N s 1647

Hemorrhage 0 0 3.5 2.8 4.6 5.6 3.9 3.3

Acute myocardial 0 0 0 0.5 0.4 1.1 0 0.7
infarction
Post-operative fever 0 0 1.8 2.5 0.36 5.6 0.4 1.3
or infection
Intestinal obstruction 0 25.0 0 0 0.5 1.1 0 0.1
Urinary complications 0 0 0 0.3 0.3 0 0 1.3
Injury to bladder 0 25.0 0 0.3 0.1 0 0 0.1
or ureter
Accidental perforation: 0 50.0 1.8 2.3 1.4 0 2.2 1.2
blood vessel, nerve or organ
Any complication 0 50.0 7.0 7.9 10.1 13.3 5.7 7.3
a
Abre¨ iations: L ª A represents a hysterectomy that includes laparoscopy to confirm the diagnosis and, consequently, the need
to complete the surgery via the abdominal route. L ª V represents a hysterectomy that includes laparoscopy to confirm the
diagnosis and, consequently, the ability to complete the surgery via the vaginal route. AH, abdominal hysterectomy; VH, vaginal
hysterectomy.

Because of small sample sizes, it was not possi-
ble to compare the complication rates reported
for DDH and non-DDH patients. In order to
compare the complication rate for AH and VH,
the rates for the DDH and non-DDH groups
were combined. Significant differences in favor of
VH were detected for post-operative fever or
infection Ž P- 0.005., intestinal obstruction Ž P-
0.003., urinary complications Ž P- 0.003. and the
overall complication rates Ž P- 0.002. ŽTable 4..
Table 5 converts the findings into potential
savings per 1000 hysterectomies among patients
with uterine weights less than 280 g. The savings
were most dramatic. Incorporating the guidelines
and performing vaginal hysterectomy for all
Type I patients with vaginal accessibility would

Table 5
Impact of applying the decision rule a

Diagnostic type Outcomes associated with Savings per case Savings per
and outcome Current Recommended Mean Ž%. 1000 cases
surgery surgery

Type Ib AH VH
Charges ŽUS$. 6182 4998 1184 19.2% 1 184 000
LOS Ždays. 4.05 3.03 1.02 25.2% 1020 days
Complications 9.1% 7.4% 1.7% 18.9% 17 cases wro complications

Type IIc AH LªV

Charges ŽUS$. 6393 6208 185 2.9% 185 000
LOS Ždays. 4.10 2.43 1.67 40.8% 1670 days
Complications 10.7% 7.3% 3.4% 31.8% 34 cases wro complications
a
Abbre¨ iations: AH, abdominal hysterectomy; VH, vaginal hysterectomy.
b
Type I patients displayed pathology confined to the uterus.
c
Type II patients displayed pathology extending beyond the confines of the uterus and, in most cases, Type I conditions.
168 S.R. Ko¨ ac r International Journal of Gynecology & Obstetrics 71 (2000) 159᎐169
have resulted in savings of US$1 184 000 for every
1000 procedures performed at the study hospital.
Applying the guidelines would free 1020 patient-
bed days and result in approximately a 20% re-
duction in complications.
5. Discussion
Two outcome-based studies have shown that by
using a formal decision process, such as the one
presented here, physicians can perform VH in
approximately 77᎐89% of their patients w3,10x.
The results of the current study support these
findings and also show that economic outcomes
ᎏ hospital charges and length of stay ᎏ and
medical outcomes, specifically complication rates,
are significantly improved when the surgeon uses
formal guidelines to select the appropriate hys-
terectomy route.
The economic benefits of using a formal deci-
sion process were especially apparent among
women whose conditions were confined to the
uterus. The guidelines recommend VH when the
disease is confined to the uterus, as in the case of
prolapse, small symptomatic leiomyomata, ade-
nomyosis, recurrent or severe dysfunctional uter-
ine bleeding, or carcinoma in situ of the cervix.
Thus, in the DDH group, VH was performed in
all 609 women with disease confined to the uterus
ŽType I patients. at a mean charge of US$4343 or
US$4719, depending on uterine weight. Contrast
this with the non-DDH group, where both AH
and LAVH were performed at mean charges of
US$6230 and US$7500, respectively, in some
low-uterine-weight Type I patients. Had physi-
cians used a formal decision process to direct
these women to the clinically appropriate VH
route a mean savings per case of US$1184 would
have been realized, and the complications and
higher hospital charges associated AH and LAVH
could have been avoided.
For patients with disease suspected to extend
beyond the confines of the uterus ŽType II., the
benefits of the guidelines were reflected in the
frequency of diagnostic laparoscopy and the con-
version to VH. The guidelines recommend la-
paroscopic examination when pathology appears
to extend outside of the uterus. In the DDH
group, the laparoscope was employed in 96% of
such cases and, after documenting the absence of
pathologic contraindications, 93% of those diag-
nostic laparoscopy cases were completed vagi-
nally. In comparison, in the non-DDH group,
physicians performed diagnostic laparoscopy in
only 3% of Type II patients and completed 36%
of these diagnostic laparoscopy cases abdomi-
nally. The limited use of the laparoscope by
physicians in the non-DDH group may reflect
they were confident enough in their diagnostic
skills that they did not require laparoscopic evi-
dence to confirm the severity of the disease or
they were convinced that AH is required when-
ever the pathologic condition is suspected to ex-
tend beyond the uterus. However, since both the
DDH and non-DDH groups were similar, one can
assume that had the severity of the disease been
confirmed laparoscopically, more women would
have undergone VH.
Traditionally, the history, physical examination,
and imaging techniques, such as ultrasound and
X-ray studies, have been used to determine
whether pathology extended beyond the uterus.
However, several investigators have proven that
these techniques are not sufficiently accurate to
adequately document the severity of conditions
such as endometriosis, adnexal pathology, chronic
pelvic pain, and pelvic inflammatory disease
w3,11,12x. As this analysis shows, judicious use of
the laparoscope to precisely document the sever-
ity of the disease process when indicated yields
significantly improved medical and economic out-
comes.
The data on complications reported in this
study for AH and VH were statistically different
and support the results of previous studies
showing that the vaginal route is associated with
fewer complications. Overall complication rates
for the surgeons in this study, however, were
similar regardless of whether the surgeon used
formal guidelines presented here or another, less
formal process to determine the route of hys-
terectomy. This was to be expected because gyne-
cologic surgeons choose procedures in which they
are experienced and have surgical competence.
 S.R. Ko¨ ac r International Journal of Gynecology & Obstetrics 71 (2000) 159᎐169
At the teaching hospital where this study was
conducted, the ratio of AH to VH was approxi-
mately 1.2:1, much lower than the national ratio
of 2.06:1, which demonstrated that the surgeons
in this study were highly skilled in VH techniques.
However, with the application of the formal
guidelines presented here, the VH rate increased
even more.
This study is not without its weaknesses. The
effect of confounding variables, such as age dif-
ferences, preexisting medical conditions, and con-
comitant surgeries, including oophorectomy, vagi-
nal repairs, and incontinence procedures was not
analyzed, even though they could have affected
LOS and cost. Likewise, the decision process used
by physicians in the non-DDH group was not well
defined but was assumed to reflect their training
or personal practice style. Despite these weak-
nesses, the data show the benefits of decision-
directed hysterectomy.
In today’s managed-care environment, physi-
cians increasingly are being pressured to adopt
evidence-based practice guidelines that are cost-
effective and defined by outcomes rather than
physician preference or experience. The results
presented here demonstrate that when gyneco-
logic surgeons base their surgical decisions on the
extent of the pathologic condition actually pre-
sent rather than presumed to be present, women
receive the best and cost-effective medical care.
When physicians confirm the severity of in-
traoperative pathology, they increase the number
of VH procedures they perform, allowing physi-
cians, patients, and third-party payers to take full
advantage of the medical and economic benefits
of the vaginal approach.
In conclusion, gynecologic surgeons have an
obligation to their patients to demonstrate that
the route of hysterectomy they choose not only
benefits the patient medically, but represents a
wise use of health-care dollars. This study shows
that AH is clearly indicated in cases of serious
disease if it is documented to extend beyond the
pelvis, but not if the choice is made based merely
on physician preferences. Developing clinical
guidelines is the first step in ensuring that most
appropriate route of hysterectomy is selected that
169
is cost-effective and meets the standard of quality
care.
Acknowledgments
Statistical analysis was supported in part by an
unrestricted educational grant from Ethicon
Endo-Surgery, Cincinnati, Ohio.
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