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The shift from inpatient to outpatient hysterectomy for endometrial cancer in the United States: trends, enabling factors, cost, and safety
  1. Serena Cappuccio1,2,
  2. Yanli Li3,
  3. Chao Song3,
  4. Emeline Liu3,
  5. Gretchen Glaser1,
  6. Jvan Casarin1,
  7. Tommaso Grassi1,
  8. Kristina Butler4,
  9. Paul Magtibay4,
  10. Javier F Magrina4,
  11. Giovanni Scambia2,
  12. Andrea Mariani1 and
  13. Carrie Langstraat1
  1. 1Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Department of Woman's, Child's and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
  3. 3Global Health Economics and Outcomes Research, Intuitive Surgical Inc, Sunnyvale, California, USA
  4. 4Department of Gynecology, Mayo Clinic, Phoenix, Arizona, USA
  1. Correspondence to Dr Carrie Langstraat, Department of Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota, USA; langstraat.carrie{at}


Objective To evaluate trends in outpatient versus inpatient hysterectomy for endometrial cancer and assess enabling factors, cost and safety.

Methods In this retrospective cohort study, patients aged 18 years or older who underwent hysterectomy for endometrial cancer between January 2008 and September 2015 were identified in the Premier Healthcare Database. The surgical approach for hysterectomy was classified as open/abdominal, vaginal, laparoscopic or robotic assisted. We described trends in surgical setting, perioperative costs and safety. The impact of patient, provider and hospital characteristics on outpatient migration was assessed using multivariate logistic regression.

Results We identified 41 246 patients who met inclusion criteria. During the time period studied, we observed a 41.3% shift from inpatient to outpatient hysterectomy (p<0.0001), an increase in robotic hysterectomy, and a decrease in abdominal hysterectomy. The robotic hysterectomy approach, more recent procedure (year), and mid-sized hospital were factors that enabled outpatient hysterectomies; while abdominal hysterectomy, older age, Medicare insurance, black ethnicity, higher number of comorbidities, and concomitant procedures were associated with an inpatient setting. The shift towards outpatient hysterectomy led to a $2500 savings per case during the study period, in parallel to the increased robotic hysterectomy rates (p<0.001). The post-discharge 30-day readmission and complications rate after outpatient hysterectomy remained stable at around 2%.

Conclusions A significant shift from inpatient to outpatient setting was observed for hysterectomies performed for endometrial cancer over time. Minimally invasive surgery, particularly the robotic approach, facilitated this migration, preserving clinical outcomes and leading to reduction in costs.

  • endometrial neoplasms
  • hysterectomy
  • surgical oncology
  • postoperative complications
  • gynecologic Surgical Procedures

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  • Contributors SC, CL, AM, YL: Study concept, data analysis and writing of the manuscript. CS: Study concept, review and revision of the manuscript. EL: Study concept, overseeing of study conduct, review and revision of the manuscript. JC, GG, GS, JFM, PM, KB, TG: revision of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests CS reports personal fees from Intuitive Surgical, outside the submitted work. YL is a full-time employee and stock holder of Intuitive Surgical.

  • Patient consent for publication Not required.

  • Ethics approval As this was a retrospective, observational study using de-identified patient data in the PHD, it is fully compliant with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, and was deemed exempt from Institutional Review Board approval.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. The data that support the findings of this study are available from Premier Inc. Restrictions apply to the availability of these data, which were used under license for this study.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.