Study design, materials and methods
The Comprehensive Hospital Abstract Reporting System, a Washington State administrative inpatient claims database, was queried for female patients age 20 or older with a diagnosis of VP and/or RP and associated surgical procedures from 2008-2019. Rates were adjusted by age, population, and gender based on WA State Census results.
Results
Query of the CHARS database identified 17,840 female inpatient admissions with both a diagnosis of VP and/or RP and a vaginal and/or rectal prolapse procedure. Of those, 15,279 underwent VP repair alone and 918 underwent combined rectal and vaginal prolapse repair. The majority of women identified in our query were < 80 years old, 52% identified as White, and 4.83% of the population identified as minority groups. However, 43.14% of the population in the database did not provide data regarding ethnicity.
Seventy-five percent of all VP or RP inpatient surgeries were performed in the 7 most populated WA State counties. The majority of all combined vaginal and rectal prolapse procedures were performed in 10 facilities in a single county (King county, which includes the Seattle metropolitan area). The majority of patients identified in the query reside within 5 counties, and 75% of patients live within 20 miles of their treating facilities (Table 1). Among the top 15 centers performing VP and RP prolapse surgery, one center’s patient population was noted to be composed of 95% of patients that resided more than 20 miles away.
Between 2008-2019, inpatient admissions for concurrent VP and RP prolapse surgery remained stable, with adjusted rates ranging from 1.42-3.38 per 100,000, and 95% of combined procedures being performed in patients <80 years old (Figure 1). The adjusted rate of inpatient RP repairs also remained stable, 3.12-5.14 per 100,000, with 82% being performed in women <80 years old. The adjusted rate of inpatient VP repairs decreased, from 81.78 per 100,000 in 2008 to 6.96 per 100,000 in 2019, and 94% of surgeries were performed in women <80 years old.
Interpretation of results
Prior work has demonstrated that there has been a nationwide trend of increasing utilization of multidisciplinary approaches toward treating concurrent vaginal and rectal prolapse [1]. However, the same trend for concurrent VP/RP surgery has not been clearly identified in Washington State. This data suggests that despite a nationwide trend toward multidisciplinary approaches, this trend may not be occurring at similar rates in each state. Additionally, the previously reported rates were not adjusted for population, age, or gender, suggesting that although there was a significant nationwide increase in the number of combined VP/RP prolapse procedures, a straightforward comparison of these results to the above-reported adjusted rates may be difficult.
The procedure rates described herein were obtained using the CHARS database, which collects information on inpatient and observation patient community hospital stays. The majority of RP surgeries are performed as inpatient procedures and would be reported in the CHARS database. VP surgery can be performed in an inpatient setting or in an outpatient setting. One of the limitations of using this State level resource is that only inpatient VP surgery is recorded in the CHARS database. The reporting of only inpatient VP surgeries is a limitation that prevents an accurate analysis of broader trends in VP and its procedures. However, combined rectal and vaginal prolapse surgery data is reported in this inpatient database, so this trend could be analyzed.
During this time period, inpatient VP surgery was shown to decline. Previously published literature has demonstrated an increasing utilization of outpatient urologic procedures, suggesting that this trend could represent an increase in utilization of outpatient VP surgeries or a true decrease in VP surgery over time. The shift of surgery from inpatient to outpatient possibly reflects the U.S. healthcare system’s shift toward more cost-effective outpatient settings and insurance reimbursement patterns.
The prevalence of VP has been found to vary across racial groups, and racial disparities have been identified in women undergoing pelvic organ prolapse surgery. For this reason, we were interested in evaluating the trends in multidisciplinary approaches in treating prolapse across racial groups. Low rates of VP/RP surgery was noted in minority groups, however this observation could not be clearly assessed using the CHARS database as racial information was not provided in 43.14% of the patient population.
The majority of all inpatient VP, RP, and VP/RP prolapse surgeries were performed in the most populated counties in Washington State, and the majority of patients live within a 20 mile radius of their treating facilities. Only one facility’s patient population was nearly entirely composed of patients that resided more than 20 miles away. It should also be noted that the distances described here are straight line distances and may not be an accurate reflection of the time required to travel to treatment centers, particularly in Washington State, where patients may need to utilize ferry services in order to reach the more densely populated regions where higher volume facilities are located. Patients electing surgical management are more likely to travel further, as do patients travelling from areas with fewer females and older people. Distance travelled to reach care may be a barrier to patient care, and longer distances travelled has been associated with later presentation to care, and greater likelihood of planning surgery at presentation. There may be a multitude of reasons for this, including patients electing treatments that require fewer follow ups due to the long distances required for follow up, or patients who have failed conservative therapies at facilities closer to their homes.
Additional limitations include the limitations of the CHARS database such as the lack of recorded clinical variables, including outcomes, complications, recurrence, and patient-specific variables. These results reported here are not generalizable as they are specific to Washington State. Strengths of the analysis include the ability to adjust surgery rates by gender, state population, and age. In addition, all patients undergoing inpatient VP, RP, and concurrent VP/RP procedures in Washington State are included, and not limited by insurance status. This analysis demonstrates the trends in concurrent VP and RP surgery as a representation of the utilization of multidisciplinary care, which has been reported to have increased nationwide, but has not increased on a State level. Although there could be many as yet unidentified reasons why this increase is not occurring in Washington State which cannot be clearly identified using the CHARS database, this smaller scale analysis is able to identify specific States such as Washington State that do not follow the previously demonstrated nationwide trend and may benefit from increased efforts to provide multidisciplinary care.