Improving the clinical performance of medical organizations is a top priority of many healthcare purchasers and payers who have an eye on costs. In Florida, however, a physician network has undertaken an initiative to analyze and improve a basic clinical procedure as part of its effort to offer better care for its patients, and, in the long run, to save on costs.
Vivra Women's Health, an obstetrician/gynecologist physician network serving Florida's Dade, Broward and Palm Beach counties is encouraging the performance of laparoscope-assisted vaginal hysterectomies in lieu of the more traditional total abdominal hysterectomies (TAH). Unlike TAH, laparoscope-assisted vaginal hysterectomies, or LAVH, require no surgical cut across the abdomen.
"We believe that reducing the number of TAHs is undoubtedly (practicing) better medicine," says Omar Pasalodos, M.D., Vivra's medical director. "We see fewer complications in patients, shorter hospital stays and a quicker return to work. Patients like the results and HMOs like the results because they keep employers happy."
Pasalodos says Vivra, which has approximately 550 South Florida OB/GYNs and 870,000 covered lives through six health plans, tracked hysterectomy statistics and found that the rate of TAHs in their service area was higher than the national rate, creating an opportunity for quality improvement.
Data for 1997 indicated an annual hysterectomy rate for the overall network of approximately 1.8 per 1,000 enrollees; the Medicare rate was 2.0 per 1,000 Medicare lives; and the commercial rate was 1.73 per 1,000 commercial lives.
The network mix of hysterectomies was found to be approximately 80% abdominal, 15% vaginal-only and 5% laparoscope-assisted vaginal hysterectomies. The National Hospital Discharge Survey for 1988 to 1990 reported that nationally, 75% of hysterectomies were performed via the abdominal approach, while 25% were performed through the vagina.
In a letter to health plan directors announcing Vivra's initiatives, Pasalodos said that abdominal hysterectomies "result in a longer length of stay in the hospital, increased incidence of complications, higher costs and longer recuperation time for patients. As a result, the network would like to encourage less invasive procedures, such as the laparoscope-assisted vaginal approach when it is clinically appropriate."
Information from the 1996-1997 Procedure Book shared with network physicians showed LAVH had significantly fewer complications than abdominal hysterectomies.
LAVH also resulted in an average hospital stay of one to two days rather than three to four days, a return to function in one to two weeks rather than four to six weeks and an average hospital cost two-thirds of that for an abdominal hysterectomy. The Procedure Book is published by the Center for Healthcare Industry Performance in Columbus, Ohio.
To encourage physicians to consider performing LAVH when appropriate, Vivra joined with TAP Pharmaceuticals to conduct a January 1998 physician education program that focused on alternatives to hysterectomies and minimally invasive hysterectomy procedures. Physicians earned CME credits in exchange for participating. TAP manufactures Lupron, a drug that is often used in advance of vaginal or laparoscope-assisted vaginal hysterectomies to reduce the incidence of fibroids.
One of the program's presenters was Steven McCarus, M.D., medical director of the Chicago Institute for Minimally Invasive Surgery at St. Francis Hospital and Health Center, Blue Island, Ill.
McCarus, who has been involved with minimally invasive surgery since 1985, says Vivra's action is "unprecedented" in making educational resources available and taking an aggressive approach toward encouraging minimally invasive surgery.
"We believe that LAVH is a better technique than TAH in terms of morbidity and cost," McCarus says. "The problem has been that payers haven't reimbursed adequately for that approach, even though it is harder to perform. We've asked doctors to learn a new technique without the reimbursement being there.
"Vivra had the foresight to look at the total cost and realize it can be lower because patients leave the hospital sooner and can return to work sooner," he says. "The potential for higher cost on the front end in the operating room can be made up with the lower costs on the back end. This is clearly good medical practice."
Pasalodos says network physicians had been performing TAH because they were used to it, they got good results and they believed they were being reimbursed appropriately. In addition, those doctors who first tried LAVH found it was more tedious and time-consuming. Since then, they have become more proficient in performing LAVH, Pasalodos says. Plus, Vivra now is paying higher rates for the less invasive alternatives to TAH.
Approximately 50 network physicians attended the educational sessions to hear McCarus along with Steven R. Lindheim, M.D., an assistant professor at Columbia Presbyterian Medical Center, New York, and Thomas G. Stovall, M.D., professor and vice chairman, University of Tennessee Department of Obstetrics and Gynecology, and clinical chief of women's health services for the University of Tennessee Medical Group.
Pasalodos says those attending said the seminar was useful, and some indicated they would try to modify their practice patterns.
Since then, two-day training programs on LAVH have been offered to selected physicians who can then train their colleagues.
Pasalodos says Vivra is working to increase health plan involvement in the educational programs.
"If physicians realize that the plans are behind this procedure, the training will be more attractive," he says. Vivra also wants to work with the healthcare plans on patient education, so women will begin to ask about the LAVH procedure and whether it is appropriate for them.
Meanwhile, Vivra is conducting education programs for both physicians and patients on the use of uterine balloon therapy on patients with abnormal uterine bleeding. An increase in the use of balloon therapy would reduce the overall number of hysterectomies, because it is sometimes an appropriate alternative to hysterectomy.
McCarus echoes the need to concentrate on patients as well as doctors. "Patient education needs to be the driving force," he says. "Exposure of Vivra's results will lead to greater use of LAVH around the country."
In a "Statement on Hysterectomy and its Alternatives," the American College of Obstetricians and Gynecologists said, "While it is not possible to assign an ideal rate for hysterectomy, due to insufficient scientific data and the numerous variables associated with this procedure, the rate of alternative treatments to hysterectomy can and will increase substantially, given the following scenario:
1) the widespread education of both physicians and patients on new and alternative treatments for uterine conditions;
2) increased physician training in new technology for alternative surgical treatments;
3) increased research on all aspects of hysterectomy, including its indications, alternatives and outcomes."
In other research on alternative hysterectomies, a membership survey by the American Association of Gynecologic Laparoscopists reported only one death per 14,911 laparoscope-assisted vaginal procedures, as well as a reduction in the number of TAHs performed by the respondents.
An Association spokesman said the results "reveal what many endoscopists have felt all along -- endoscopic technology is progressing as a safe and effective alternative to total abdominal and vaginal gynecologic surgery for women."
In addition, a report in the January 1998 issue of Obstetrics and Gynecology,published by the American College of Obstetricians and Gynecologists, found that postoperative health status improved significantly faster after LAVH than TAH and total costs for LAVH were more than 20% lower than those for TAH. The study was performed at Sahlgrenska University Hospital in Goteborg, Sweden.
Pasalodos believes that by the end of 1998, Vivra will have collected enough data to draw conclusions about practice patterns, quality of care and cost.
"To date, we've just been talking about this," McCarus says. "There hasn't been any data. Now Vivra is giving us the opportunity to get the data we need to promote this approach. I'm very excited about it."
John G. Hope is a Harrisburg, Pa.-based writer who formerly worked in healthcare communications.