ORLANDO – The American College of Obstetricians and Gynecologists is taking steps intended to reverse the declining rates of vaginal hysterectomy, the preferred procedure for benign indications, according to an outline of plans presented at the annual scientific meeting of the Society of Gynecologic Surgeons.
The immediate focus is on building skills both during and after training programs, said Dr. Sandra A. Carson, ACOG’s vice president for education. She reported that overall rates of hysterectomies have been declining over the past decade, but the decline has been especially steep for vaginal procedures. This has an adverse impact on training.
“Data show that over the past 10 years, residents have performed on average 8 fewer hysterectomies, but the average number of vaginal hysterectomies has been essentially halved to 17 or 18 over 4 years of residency training,” said Dr. Carson, who made her remarks as part of the invited TeLinde lecture.
This rate of vaginal hysterectomies during training is generally considered to be insufficient to provide training graduates with the confidence to perform them in routine practice, she said.
The vaginal approach has long been identified by ACOG as the preferred route of hysterectomy for benign disease because of evidence of better outcomes and fewer complications. In an ACOG committee opinion #444 entitled “Choosing the Route of Hysterectomy for Benign Disease” (reaffirmed in 2011), laparoscopic, abdominal, and robotic procedures were characterized as alternatives when vaginal hysterectomy is not feasible (Obstet. Gynecol. 2009;114:1156-8).
“We know that vaginal hysterectomy overall is better for women, so we need to get honest with ourselves about doing something about the trends,” she said at the SGS meeting, jointly sponsored by the American College of Surgeons.
Of strategies to reverse the trend, training is key, said Dr. Carson. This has led ACOG to develop several programs, including a CME-accredited surgical skills training module that includes objectives, instruction, information on how to construct a low-cost simulator, and an assessment tool. There is also a program available designed to help teachers teach vaginal hysterectomy.
ACOG also is developing a task force of teachers for mentoring. The goal is to advise surgeons who have learned the techniques of vaginal hysterectomy but may not yet have the confidence to perform them on their own. Ten experts already have volunteered to serve on the task force, and several training programs have expressed interest in receiving this form of support, Dr. Carson said.
However, she acknowledged several potential obstacles for widespread implementation of the task force that require resolution, such as providing credentialing, liability insurance, and reimbursement for advisers. ACOG has been active in considering solutions for each of these, such as using operating room cameras that would allow advisers to participate remotely.
In addition to training, however, Dr. Carson reported that ACOG is looking at strategies to align incentives that would encourage vaginal hysterectomies. This could include convincing third-party payers to provide greater reimbursement for an approach that may be less costly than alternatives, particularly robotic hysterectomy.
“We all need to decide that this is the right thing for women, but if you want to do this, we want to help you,” Dr. Carson told the audience of gynecologic surgeons.
Concern about the declining rates of vaginal hysterectomy is not new, said Dr. Ernest G. Lockrow, professor and vice chairman obstetrics and gynecology, Uniformed Services University of the Health Services, Bethesda, Md. In an interview, he suggested that there has long been hand-wringing about how to halt the decline in the approach. What is new, according to Dr. Lockrow, is the ACOG commitment for change.
“Based on what we heard today, it appears that ACOG is getting a little more serious about doing something about this issue,” Dr. Lockrow said. He is not certain how effective the strategies outlined by Dr. Carson will be in turning around current trends, “but I think we are seeing some steps in the right direction.”
Dr. Carson reported no relevant financial disclosures