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Journal Club Roundtable www.AJOG.org

iscussion: ‘Physician gender, specialty,nd hysterectomy utilization’ by Gretz et al

n the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, andmplications for future research. Article discussed:

retz H, Bradley WH, Zakashansky K, et al. Effect of physician gender and specialty on utilization of hysterectomy in New York, 2001–2005. Am J Obstet

ynecol 2008;199:347.e1-347.e6.

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DISCUSSION QUESTIONS

Is a retrospective population survey anappropriate study design?What are the benefits of the datasource?What limitations exist with this researchmethod?Would you have included subspecialistsin this analysis?What variables other than gender orspecialty might affect the outcome?Were the statistical analysesappropriate?What fuels the perceptions that malephysicians overuse hysterectomy andfemale physicians underuse it?

rom the University of Alabama-irmingham School of Medicine,irmingham, AL:

oderatorodd Jenkins, MDssociate Professor, Division of Women’seproductive Healthcare

iscussantserod Greer, MDlinical Fellow, Division of Women’s Pelvicedicine

uisa Wetta, MDourth-Year Resident, Obstetrics andynecology

my Doss, MDecond-Year Resident, Obstetrics andynecology

002-9378/$34.002008 Mosby, Inc. All rights reserved.

oi: 10.1016/j.ajog.2008.08.018

See related article, page 347

For summary and analysis of this

odiscussion, see page 438

NTRODUCTION

ver the last 2 decades, the workforce ofbstetrician-gynecologists in the Unitedtates has been undergoing a major tran-ition from male to female predomi-ance. More women are entering alledical subspecialties; however, no sub-

pecialty has undergone a more rapidhange than obstetrics and gynecology.ow will this shifting demographic af-

ect patient care? A new study by Gretznd colleagues, which is discussed in thisonth’s meeting of the Journal Club, ex-

mined 1 facet of that question: specifi-ally, whether rates of hysterectomy dif-ered by physician gender for patientsho were in the Empire Blue Cross andlue Shield (BCBS) network between theears 2001-2005.Todd Jenkins, MD and George A. Ma-

ones, MD, MSCE

TUDY DESIGN

enkins: Is a retrospective populationurvey an appropriate study design tonswer the research question posed byretz and colleagues: Does the use ofysterectomy differ based on physicianender or subspecialty?oss: I think that a retrospective popu-

ation survey is probably the only studyesign that could have answered thisuestion. A prospective study designould have been very challenging. Studyarticipants often behave or act more

ike expected norms when they knowhey are being studied. This phenome-on is known as the Hawthorne effect.

etta: This study design allowed the au-hors to look at a large number of pa-ients and physicians in a readily accessi-le database, which was queried easily to

btain the information of interest. I c

OCTOBER 2008 Am

hink that this study required the use of aarge database. In this case, the research-rs used the Administrative Data Ware-ouse Claims Database of Empire BCBS.enkins: Is there any other way that thistudy could have been performed?reer: Probably not. It is 1 of the fewesigns that would have given the largeumber of patients that was available tovaluate in this particular database.enkins: What are some of the benefitsf the database that was used?

etta: It was a very large database, withpproximately 3.2 million covered livesvailable for evaluation. The authorsere able to evaluate 48 months of

laims data. The large number of claimss a huge benefit.

oss: I think that it was very importanthat these claims included both inpatientnd outpatient charges and claims. Sim-lar studies usually use discharge data-ases, which do not capture outpatient

nformation.enkins: I would like to reemphasize thathe study period allowed the evaluationf 4 years of data. I think that this widernapshot gives a better representation ofverall practice and is not influenced asuch by subtle trends that may occur

rom year to year.reer: This database also covered a fairly

arge geographic area. It was not limitedo New York. Empire BCBS covers sev-ral surrounding states.enkins: What limitations of this re-earch method should we highlight?

oss: I think that 1 of the key limitationsf any database is that the output is al-ays limited by the quality of the input.here is room for human error in datantry. In this particular type of study,ou are dependent on the people who

hose the International Classification of

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Journal Club Roundtable www.AJOG.org

e

iseases, Ninth Revision, Clinical Mod-fication (ICD-9) codes and the Currentrocedural Terminology (CPT) codes,n the people who entered the codes, andn the actual codes that were selected forbstraction. I believe studies have dem-nstrated a significant error rate whenCD-9 codes and CPT codes were usedor research purposes.

reer: We were involved with the Child-irth and Pelvic Symptoms Study thatas published in 2007. This study looked

t the rate of anal sphincter laceration ataginal delivery. The rate of incorrectoding in this trial was 23.4%.1

enkins: I think that the article thatdentified this error rate also cites sim-lar error rates in the orthopedic, car-iovascular, and hospital-complica-ions literature. You are right; theatabase is only as good as what is put

nto the system. Another point that Iould like to bring to the table is the

act that we have no information re-arding patient preoperative work-up.

e do not know how long they werereated before they had surgery. Itould be important to determinehether gender affects how soon hys-

erectomy is offered. We are not givenny information on the length of med-cal management, observation, or theumber of minimally invasive proce-ures each patient underwent.enkins: Would you have included gy-ecologic oncologists in this database?

etta: I probably would not have in-luded them. Most of the treatments thatre provided by gynecologic oncologistsnvolve surgery. Most of their patientsre treated after consideration of evi-ence-based protocols that mandateurgery.enkins: I think that is a very importantoint. Gender does not influence proto-ols or guidelines in the same mannerhat it affects personal decisions. I wouldxpect to see very little difference be-ween treatments that were selected by

ale and female gynecologic oncolo-ists, simply because of their use of Gy-ecologic Oncology Group protocols. Iould not have included them either.oss: They do not use a great deal ofedical management. Most of their

edical management involves chemo- M

2 American Journal of Obstetrics & Gynecology O

herapy or radiation, which usually oc-urs postoperatively.enkins: Dr Greer, as our urogynecolo-ist, would you have included your sub-pecialty in this analysis?reer: I think that it probably wouldave been more appropriate to includerogynecologists than gynecologic on-ologists. The number of hysterectomieshat are performed by urogynecolo-ists is probably a little bit lower thanhe number performed by gynecologicncologists.enkins: Do you believe that most uro-ynecologists are doing hysterectomiess part of prolapse surgery, or are theyetaining the uterus and simply repairinghe pelvic floor defects?reer: In my experience, uterovaginalrolapse is treated with a hysterectomy,nless the patient has a strong desire toetain the uterus.enkins: For that reason, I also have con-erns about including urogynecologistsn this database, because most patientsre referred to them with a diagnosis thatequires fairly specific treatment, whichsually includes a hysterectomy. I agree

hat more room exists for personal pref-rence/gender bias than in gynecologicncology; however, I still think that uro-ynecologists have fewer managementptions to choose from for their specialatient population than the average ob-tetrician-gynecologist.enkins: Does this particular databaseave any other limitations?

etta: Another limitation is that EmpireCBS only represents 1 small segment of

he overall population. This might pos-ibly be a wealthier or more educatedopulation. By using a single insurer, theesearchers have excluded large seg-ents of the general population and

hose physicians who do not accept Em-ire BCBS. I think that they have limitedhe generalizability of their study by us-ng only 1 insurer.enkins: How could you have improvedhe study?

etta: I think that you could have at-empted to include multiple insuranceroviders.reer: Other private insurers could haveeen included, as well as Medicare and

edicaid. s

CTOBER 2008

enkins: That would definitely haveiven the authors a better cross-sectionf the population and would haveade the study more generalizable.ne of the largest concerns that I haveith respect to the use of a single in-

urer is the fact that most private car-iers have strict guidelines or protocolshat must be met before the authoriza-ion of a hysterectomy. Therefore, I amoncerned that this study representsdherence to the guidelines rather thann effect caused by gender. The pur-ose of guidelines is to standardize carehat is based on disease. I believe theesults of this particular study mayimply represent network physicians’dherence to the Empire BCBS criteriaor hysterectomy. Adherence to guide-ines reduces the potential for personalias or gender-related bias.I also had questions regarding the sin-

le geographic region that was examinedn this study. Most hysterectomy studiesave shown differences in the use of hys-erectomy based on the geographic areaf the country surveyed. This study was

imited to the Northeastern Unitedtates and specifically, the metropolitanew York area. Therefore, the data mayot be applicable to other areas of theountry. The other thing that might in-uence the negative result that was ob-

ained in this study is the consistency ofare in geographic areas. Most physi-ians practice in the geographic region inhich they trained. They use mentors at

heir training institutions to assist withifficult cases. Therefore, you often willet a consistency of practice that is basedn similar training.In addition, I think that you get the

ame patient characteristics when youimit the study to a geographic region.or example, we practice in the south-astern United States, which is an areanown for higher-than-average hyster-ctomy rates. For many of our patients,ysterectomy is not viewed as a negativeutcome. When they are given options,any of our patients will choose hyster-

ctomy over other medical treatments orinimally invasive procedures. That isore of a patient-derived variable rather

han 1 that would be influenced by phy-

ician gender or subspecialty.

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www.AJOG.org Journal Club Roundtable

DDITIONAL CONFOUNDERS?enkins: Do you see any other limita-ions to this database?

oss: The only other thing that I wasoncerned with was whether a prolificurgeon or group of surgeons could havekewed the data in favor of their gender.hat could be a confounder that has noteen accounted for previously.enkins: We have discussed insurers’ cri-eria for surgery, subspecialists’ guide-ines or protocols, and patient variables.an anyone identify other variables

hat might shape the physician’s deci-ion to proceed with hysterectomy?reer: Aside from the physician’s train-

ng site, the length of time since a physi-ian completed his or her training wouldffect the use of hysterectomy. I thinkhat it would influence how they man-ged or proceeded with the evaluationnd treatment of these patients. Recentraduates would be more familiar withertain minimally invasive techniquesnd would be more comfortable usinghese measures; more senior physicians

ight be more comfortable with hyster-ctomy than with other options.enkins: Another important variablehat is related to physician age is the agef the patients whom they are treating.necdotally, the younger physicians inur practice, especially the young femalehysicians, see a younger population ofomen than the do the more senior phy-

icians. Because most women who expe-ience irregular bleeding are in their late0s and 40s, physicians who care forore patients in this age bracket should

e more likely to perform hysterectomy.younger population of patients would

e healthier and require fewer surgicalreatments.

etta: I think that each physician’somfort with difficult cases representsnother variable. For example, patientsith multiple previous surgeries, medi-

al comorbidities, or morbid obesityight be steered toward more medicalanagement or less aggressive therapies

efore proceeding with hysterectomy.enkins: In many areas, especially thoseith a large volume of patients who pay

ash, there is a large amount of direct-to-

onsumer marketing. This includes ob- g

tetrician-gynecologists’ marketing ofndometrial ablation and radiologists’arketing of uterine artery embolization

r magnetic resonance– guided focusedltrasound scanning. Exposure to sucharketing may affect how patients

hoose a physician for treatment of aondition and the way they decide on alan of care.enkins: What other information woulde helpful in determining whether thempire BCBS database is appropriate

or answering this particular researchuestion?

etta: I think that it is important to as-ess whether this study population iseneralizable to the remainder of theeographic region and to the remainderf the country. I would have liked tonow the patients’ ages, education, so-ioeconomic status, and comorbidities,enerally, just a little more informationbout the patients. This would have beenelpful in determining whether they areepresentative of the overall population.reer: The inclusion of another payer

rom a different geographic region, suchs the South or the West, might haverovided results that were a little moreeneralizable.enkins: Another piece of helpful infor-

ation would have been the age of thehysicians who were included in thetudy; more than just the median age ofractitioners in each group (Table 1 inrticle). Given our previous conversa-ion, it would have been nice to know thehysicians’ age and the patient mix thatach of the providers treated. For exam-le, if a physician’s patient mix waseighted more heavily with obstetric pa-

ients, it would appear that they were us-ng hysterectomy less often. In reality,hey just had fewer opportunities to per-orm hysterectomy. I think the demo-raphics of each physician’s practiceould influence their use of hysterectomy.

TATISTICAL ANALYSES

enkins: Did anyone have any issues withhe statistics used within this study?

reer: They did talk about the use of thehi-square test and an alpha of .05, buthey did not discuss at all what they were

oing to use as a significant difference t

OCTOBER 2008 Am

etween the male and female physiciansnd their hysterectomy rates.enkins: Right. I do not think that theyrovided prestudy sensitivity informa-ion either. Were they attempting tochieve 80% or 90% sensitivity to detectheir outcome? They should have usedhis information to determine a power orhe number of patients who were re-uired to achieve significance. I alsogree regarding their failure to delineatehat they would consider a significantifference between the genders. For ex-mple, would they consider differencesf 5%, 10%, or 25% to be significant? Arestudy hypothesis regarding the rate ofignificance and the number of patientseeded to determine this differenceould have enhanced the study.

ONCLUSION

enkins: Regarding the perception thaten “abuse” hysterectomy and women

underuse” hysterectomy: The authorsuote an article regarding physician gen-er and cesarean delivery from the year000. However, this was a retrospectiveurvey of a single institution’s experienceith cesarean delivery. In this study,ale physicians were more likely to pro-

eed to cesarean delivery than were fe-ale physicians. Again, this is a single

nstitution and a retrospective study thatid not evaluate many of the other vari-bles and confounders that are involvedith the clinical decision.

enkins: Does anyone have any otherdeas as to the reason that this percep-ion exists?

oss: I think, in general, male physiciansike to fix problems. They may be quickero act in a more definitive manner thanre female physicians. Female physiciansay offer patients more options than

heir male counterparts or may be lessikely to steer patients toward a particu-ar option, whereas, male physicians mayteer women toward a surgical option.enkins: I think that you are correct inhe assessment that we have a desire tofix” the problem; often, hysterectomyeems to be the most expeditious way too so. However, I have found this desire

o be just as prevalent among our female

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Journal Club Roundtable www.AJOG.org

e

esidents as it is among our male resi-ents. I wonder if this is a historic stereo-ype that persists. It is my opinion that

ale obstetrician-gynecologists who areurrently training or have trained re-ently are just as likely to offer multiplereatment options and to respect aoman’s desire to retain— or not re-

ain— her uterus as are female obstetri-ian-gynecologists. To compete in to-ay’s market, male physicians must beensitive and break this stereotype.oss: I think this study suggests that, if a

ap existed, it has narrowed. Male obste-rician-gynecologists are possibly less ag-ressive than they were previously, andemale obstetrician-gynecologists are be-oming more aggressive.enkins: I wonder whether this studynd its results reflect something otherhan the effects of physician gender orubspecialty. Several recent studies andditorials have demonstrated that pa-ient populations who are treated on theasis of a defined, evidence-based proto-ol have better outcomes than popula-ions whose treatment is based on physi-ian preference. Most of this literature isn the obstetric arena with respect to the

se of oxytocin or cesarean delivery. c

4 American Journal of Obstetrics & Gynecology O

enkins: Finally, having read and dis-ussed this study, what are your thoughtsbout it? Do you find it reassuring thathe researchers did not identify any dif-erence between male and female physi-ians, or do you doubt the accuracy of thisesult?oss: I think that it is fairly accurate if

ou look specifically at the most recentlyrained obstetrician-gynecologists. Iannot say whether it is reflective of theverall population of obstetrician-ynecologists because I think that train-ng, patient interaction, and the role ofhe physician in patient decision-makingas changed.

etta: There may not be a difference be-ween genders in the use of hysterec-omy; however, I am not comfortable re-ying on a regional study from a singlensurer with the limitations that we dis-ussed previously to answer this clinicaluestion. I think that similar studies inther geographic regions with more di-erse populations of patients and physi-ians are necessary to answer this question.reer: I agree. Also, I think that the re-

ults are probably somewhat skewed, be-ause of the many protocols used byospitals, subspecialties, and insurance

arriers. It would be very interesting to 2

CTOBER 2008

ee what Empire BCBS’s protocol for re-mbursement for a hysterectomy in-ludes. The results might be a little moreeaningful with this information.

enkins: I found this study somewhat re-ssuring, but for a totally different rea-on. I still think a slight difference in theate of hysterectomy use that is based onender might exist. Still, this study pro-ides evidence that physicians are usingtructured management protocols anduidelines in treating their patients. Phy-icians are basing their decisions to pro-eed to surgery more on patient-relatedactors than on personal bias. They aresing evidence-based guidelines to make

hose management decisions and there-ore are coming out with similar surgeryates and, hopefully, similar outcomes. Iope that is what this study demon-trates. However, I do agree that we need

ore data from diverse geographic andemographic regions to make this ste-eotype disappear. f

EFERENCE. Brubaker L, Bradley CS, Handa VL, et al.nal sphincter laceration at vaginal delivery: is

his event coded accurately? Obstet Gynecol

007;109:1141-5.