Surgeon's specialty influences sling outcomes

Atlanta-Results of a Medicare claims analysis of women undergoing a sling procedure for stress urinary incontinence have revealed a significant variation between gynecologists and urologists in their approach to patient evaluation and the outcomes after surgery. However, further study is needed to understand the factors underlying those differences, researchers from UCLA said at the AUA annual meeting here.

Jennifer T. Anger, MD, and colleagues analyzed data extracted from a 5% national random sample of public use files provided by the Centers for Medicare & Medicaid Services. Over an 18-month period between Jan. 1, 1999 and July 31, 2000, 1,356 women age 65 years and older underwent a sling procedure with or without simultaneous prolapse repair as identified by CPT-4 codes. The outcomes assessment tracked women during the first 12 months after their surgery and used CPT-4 and ICD-9 codes to identify a variety of urologic and non-urologic complications as well as additional relevant surgeries.

The results showed that urologists performed 78.4% of the sling procedures, while a gynecologist was the surgeon in 18.1% of the cases. Prolapse was addressed simultaneously in a significantly higher proportion of procedures performed by gynecologists compared with urologists: 56% versus 29%, respectively.

"The fact that so many of these procedures were performed by urologists suggests that slings are often done by general urologists who are not addressing prolapse. If prolapse is not managed at the time of the sling, women may suffer the morbidity and cost of repeat surgery," said Dr. Anger, urological health services research fellow and clinical instructor of urology at UCLA, working with Larissa V. Rodríguez, MD, and Mark S. Litwin, MD.

"However, there are limitations to our study because it is based on claims data," Dr. Rodríguez added. "The study includes all types of slings, which may have different complication rates. Also, since Medicare recipients represent an older population of women, our findings may not be representative of sling recipients as a whole. Nevertheless, our findings are useful for suggesting trends and problems that we are now investigating further."

Differences in evaluation

The study also found that the two provider groups differed significantly in their approaches to preoperative evaluation. A significantly higher proportion of urologists than gynecologists performed cystoscopy preoperatively (31% vs. 19%, respectively), whereas gynecologists were more likely than urologists to perform urodynamic studies (41% vs. 30%).

"In a preliminary analysis, we did not find any association between lack of a urodynamic workup and a less than satisfactory outcome, but we hope to present more complete findings next year," Dr. Anger said.

The outcomes analyses showed a repeat incontinence procedure was performed in 9.3% of women operated on by a urologist and in 4.9% of those operated on by a gynecologist. The rates for subsequent prolapse repair were 26.0% for urologists and 12.2% for gynecologists. In addition, women who had sling surgery performed by a urologist were 1.7 times as likely to be diagnosed with urge incontinence than their counterparts operated on by a gynecologist. The differences between provider specialties for all of those comparisons were statistically significant.

Rates of nonurologic complications, including cardiac, pulmonary, and gastrointestinal events, as well as perioperative complications of hematoma, bladder injury, fistula, outlet obstruction, and urinary tract infection were also analyzed, and no significant differences were noted. UTI developed in about 50% of women regardless of their surgeon's specialty.

The analyses also showed that among the subjects who underwent prolapse repair, 80% changed providers from a urologist to a gynecologist. About 10% of the women stayed with their original provider, and a small proportion changed from a gynecologist to a urologist.

Discussing the limitations of the study, Dr. Anger noted the possibility that incomplete coding would result in missing reports of complications. In addition, claims data do not provide clinical and surgical information that could be used to explain some of the findings. Furthermore, the study did not account for the influence of fellowship training.