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4

hysician gender, specialty, and hysterectomy utilization:retz et al

odd Jenkins, MD; George A. Macones, MD, MSCE, Associate Editor

he article below summarizes a roundtable discussion of a study published in this issue of the Journal in light of its method, 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.

he full discussion appears at www.AJOG.org, pages e1-e4.

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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/free2008 Published by Mosby, Inc.

oi: 10.1016/j.ajog.2008.08.019

bSee related article, page 347

38 American Journal of Obstetrics & Gynecology

ver the last 2 decades, the work-force of obstetrician-gynecologists

n the United States has been undergoingmajor transition from male to femaleredominance. More women are enter-

ng all medical subspecialties; however,o subspecialty has undergone a moreapid change than obstetrics and gyne-ology. How will this shifting demo-raphic affect patient care? A new studyy Gretz and colleagues, which is dis-ussed in this month’s meeting of theournal Club, examined 1 facet of thatuestion: specifically, whether rates ofysterectomy differed by physician gen-er for patients who were in the Empirelue Cross and Blue Shield (BCBS) net-ork between the years 2001-2005.The researchers examined �1 million

utpatient and inpatient claims fromhat period, flagging hysterectomy-re-ated diagnoses as indicated by Interna-ional Classification of Diseases, Ninthevision, Clinical Modification (ICD-9)odes, and hysterectomies or alternativerocedures (myomectomy, for example)s denoted by Current Procedural Ter-inology (CPT) codes. After identifying

972 hysterectomies and 5077 alterna-ives, they found that the rates of hyster-ctomy or alternatives were similarmong male and female physicians.

NOWING YOUR LIMITATIONS

he Journal Club concluded that a retro-pective review of a large database was 1f the few study designs that could besed to assess this particular researchuestion. Similar studies have been per-ormed that used discharge diagnoses,

irth and death records, and census in- g

OCTOBER 2008

ormation. This design allowed the au-hors to review data that were related to aatient population that numbered �3illion and to assess the care that was

rovided by a large number of physi-ians. Another important advantage ofhis database was its capture of both in-atient and outpatient charges. Most da-abase studies do not include outpatientnformation because they are based onischarge diagnoses.A prospective study would not be an

ffective way to address this particularuestion because it would be vulnerableo the so-called Hawthorne effect. Thishenomenon is a temporary change inehavior or performance, typically an

mprovement, in response to a change innvironmental conditions. In otherords, if physicians knew that their be-avior was being observed, they woulddhere to traditional criteria for hyster-ctomy more often than they otherwiseight.Several limitations to the study designere considered. First, use of any dataset

s limited by the quality of the data thatre entered into the database. This par-icular study used ICD-9 and CPT codes.

recent study found that almost 25% ofnal sphincter lacerations incurred dur-ng vaginal delivery were coded incor-ectly at the time of hospital discharge.1

he authors cited similar coding errorsn the orthopedic, cardiology, and hospi-al-complications literature. Therefore,eaders should anticipate some error inhe coding of hysterectomy and hyster-ctomy alternatives in this study. Sec-nd, the dataset gives no information re-

arding the preoperative evaluation of

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www.AJOG.org Journal Club

atients, attempts at medical manage-ent, and the duration between initial

valuation with a disorder and surgicalntervention. As a result, we do not knowhether 1 gender is “faster” to operate

han another. Third, this study designannot identify prolific surgeons, maler female, who would skew the data inavor of their gender.

ONFOUND IT!arge population database studies areubject to the risk of multiple confound-ng variables. In this particular trial,hose variables were the use of data from

single insurer, a population that wasrawn from a single geographic region,nd the inclusion of subspecialists in thetudy database. Journal Club membersere most concerned that the data came

olely from the Empire BCBS insuranceatabase. Demographic factors (such ashe age, race, educational level, and so-ioeconomic status of members) mightnfluence greatly the occurrence of med-cal conditions, access to clinical infor-

ation, and involvement of the patientn the clinical decision-making process.n addition, was the Empire BCBS pop-lation comparable to the overall popu-

ation in the greater New York area?he study certainly would have been

trengthened if it included patients whoere covered by additional insurers (pri-ate and public) and patients who wereninsured.Furthermore, most insurers oblige pa-

ients to have met certain criteria beforeysterectomy is authorized. Commonequirements include certain levels ofterine disease, demonstrated anemia,

rials of medical management, and often,

revious attempts at minimally invasive s

ysterectomy alternatives. The Journallub had significant concern that the usef a single insurer led to the study’s null-ypothesis finding. If every patient has toeet similar criteria before hysterec-

omy, the physician’s personal inclina-ions and gender would have less effectn the decision to proceed to hysterec-omy than the standards set forth by thensurer. Patient-care guidelines are de-igned to result in similar outcomes foratients with similar signs and symp-oms; they override physicians’ ownreferences.Use of patients from 1 geographic re-

ion does not provide necessarily anccurate view of what is happening na-ionally. It is common for obstetrician-ynecologists to practice in the geo-raphic region in which they trained; as aesult, many practitioners in a particularrea will often have similar practice pat-erns and rates of surgical intervention.lso, local standards of care shape prac-

ice patterns. Hysterectomy rates in theouth are consistently greater than thosen the Northeast and West. This observa-ion not only represents the local stan-ard of care, but it also mirrors patient

actors. For example, many patients inhe South do not consider hysterectomyo be a negative outcome; thus, they are

ore likely to choose it when given sev-ral options. Restricting data to a North-astern population might reveal similarreatment desires among patients, ratherhan physician influences.

Our Journal Club strongly believedhat subspecialists’ care practices shouldot have been included, because theiratients, who were generally referrals,ave already been determined to needore advanced treatment that demands

pecial expertise. Most gynecologic on- 2

OCTOBER 2008 Am

ologists treat patients using well-de-ned protocols, which often require hys-

erectomy as a part of the treatment.herefore, their decision to proceed withysterectomy is less likely to be inspiredy personal or gender-related biases. Al-hough urogynecologists are less con-trained by protocols, they also care for aeferral population with specific prob-ems that necessitate specific treatments.

SIGNIFICANT DIFFERENCE?inally, a well-designed research trial de-ermines, in advance, the magnitude ofhe differences in outcomes that woulde needed to indicate a clinically signifi-ant finding. This determination, alongith a predefined study sensitivity to de-

ect this difference, can be used to per-orm a power analysis. This particularrial did not specify a difference in hys-erectomy rates between male and fe-

ale physicians that would be consid-red significant.

Despite these limitations, we com-end Gretz and colleagues for address-

ng the common perception that there isgender difference in patient care. The

nability of this study to determine a dif-erence in hysterectomy or hysterectomylternatives, based on gender, is reassur-ng. The data indicate that physicians—

ale or female—rely on medical princi-les in determining treatment, notersonal predilections. Hopefully, this isn accurate reflection of what is happen-ng elsewhere in the country. If so, an oldtereotype can finally be discarded. 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.

erican Journal of Obstetrics & Gynecology 439