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Rosemarie B. Hakim, PhD, M. Beth Benedict, DrPH, JD and Nancy J. Merrick, MD, MSPH

At the time of the study, Rosemarie B. Hakim was with the Centers for Medicare and Medicaid Services, Baltimore, Md. M. Beth Benedict is with the Centers for Medicare and Medicaid Services, Baltimore, Md. Nancy J. Merrick is with the MEDSTAT Group, Santa Barbara, Calif.

Correspondence: Requests for reprints should be sent to Rosemarie B. Hakim, PhD, Environmental Protection Agency, IRIS 8601D, 1200 Pennsylvania Ave, NW, Washington, DC 20460 (e-mail: hakim.rosemarie{at}epa.gov).

	ABSTRACT

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Objective. We assessed the quality of hospital care for women who underwent a hysterectomy to compare Medicaid-covered women with privately insured women and minority women with White women.

Methods. We evaluated medical decisions, inpatient care, quality of inpatient care, and outcomes.

Results. Quality of hospital care was equivalent for Medicaid-covered women compared with privately insured women and for non-Hispanic Black women compared with White women. Medicaid-covered women (40%) and Black women (68%) were more likely to have a complication compared with privately insured women and White women, respectively.

Conclusions. Increased complications after hysterectomy may result in increased economic burdens to Medicaid. Further studies of the racial/ethnic and sociodemographic issues are needed so that disparities may be adequately addressed.

	INTRODUCTION

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Although research has demonstrated that the Medicaid program has benefited low-income enrollees,^1,2 there is concern about the quality of care provided to Medicaid enrollees because of discrepancies between physician payments for services to Medicaid beneficiaries and payments for services to those who are privately insured.³ During the mid-1980s, a time when there were no evaluations of quality of inpatient care for Medicaid beneficiaries, Congress mandated the Health Care Financing Administration (now called the Centers for Medicare and Medicaid Services) to evaluate the quality of care provided to Medicaid-covered patients.⁴ Since then, a number of studies have hypothesized that hospitalized patients insured by Medicaid may receive care that is not equal to the care received by privately insured patients.^5,6 In response to the Congressional mandate, we studied 3 conditions that are common among patients covered by Medicaid: pediatric asthma, complicated labor and delivery, and hysterectomy. We report the results of our hysterectomy analysis; a study of quality of care provided to children hospitalized with asthma, which used the same methods, has been published elsewhere.⁷

We chose to analyze hysterectomy for 2 reasons: (1) it is one of the most costly procedures for nonpregnant women younger than 65 years and in the Medicaid program, and (2) it is a high-volume procedure and therefore of particular interest.⁸ Our choice was further influenced by a concern about the appropriateness of hysterectomy versus uterus-preserving treatments among low-income women.

	METHODS

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Study Population
We included women who were younger than 65 years and who underwent a hysterectomy in 1991 California, Georgia, and Michigan. These states were selected because of their racial and geographic diversity and their relatively large populations of Medicaid-covered residents. We chose urban hospitals because Medicaid recipients are concentrated in cities. These hospitals were selected from a 1991 American Hospital Association Survey list that was sorted into terciles by number of Medicaid discharges. Within each tercile, women who had undergone a hysterectomy were sampled on the basis of information provided by each hospital about the number of hysterectomy cases treated in 1991 to ensure each hysterectomy patient had equal probability of being sampled. Approximately 400 Medicaid and 400 privately insured patients who had undergone a hysterectomy were randomly sampled from each state. Insurance status was verified by each hospital in the sample.

Quality Criteria
We developed indicators for 3 aspects of care—appropriateness of the decision to perform a hysterectomy, quality of the process of inpatient care, and clinical outcomes—to detect differences in the hospital care provided to Medicaid-covered women who underwent a hysterectomy compared with privately insured women. We used the Rand/UCLA method of having clinical experts develop the criteria.^9,10 A panel of 9 physicians—who represented medical societies such as the American Medical Association and the American College of Obstetricians and Gynecologists—scored clinical scenarios for appropriateness of the decision to perform a hysterectomy; created quality of inpatient care criteria to evaluate inpatient monitoring, treatment, and discharge planning; and identified adverse clinical outcomes hypothesized to reflect quality of care from information available in medical records. Trained registered nurses, medical-record administrators, and medical-record technicians abstracted the data. Missing data points vital to the decision tree resulted in missing appropriateness or inpatient care scores.

Clinical scenarios were presented to the panel and were scored 1 through 9. Scores of 1 through 3 were "appropriate," 4 through 6 were "uncertain," and 7 through 9 were "inappropriate" surgery. An appropriateness indicator was judged to be equivocal if the panelists considered the benefits and the risks of performing a hysterectomy to be about the same (a median rating of 4 to 6) or if they disagreed on the rating. A series of algorithms, which were created on the basis of criteria developed by the panel, translated information abstracted from medical records into appropriateness levels. These criteria were diagnosis upon admission; severity of symptoms (anemia, amount of bleeding, pain, pressure, chronicity, incontinence); invasiveness (cancer or endometriosis); previous diagnostic procedures, medical interventions, and surgical treatments; menopausal status; and desire for children if the patient was premenopausal. When patients had more than 1 condition that led to a hysterectomy, the appropriateness algorithm was applied to the condition with the most severe symptoms. Examples of appropriateness ratings for hysterectomy are as follows:

1. Hysterectomy for asymptomatic fibroids with a 3-centimeter increase in uterine size in 1 year and a uterine size equivalent to a 12-week or longer pregnancy was rated 1 (appropriate) for postmenopausal women and 7 (inappropriate) for premenopausal women who desired a pregnancy in the future.
   
2. Hysterectomy for surgically diagnosed symptomatic endometriosis that was medically or surgically treated before the index procedure was rated 1 (appropriate) for postmenopausal women and 5 (equivocal) for premenopausal woman who desired a pregnancy in the future.
   

The panel developed inpatient care safety variables specific for hysterectomy and created 3 levels of urgency: (1) problems with care that led to a high potential for immediate harm, (2) problems with a high potential for delayed harm, and (3) care that when omitted had an uncertain or low potential for harm. For example, if the hysterectomy was not delayed when a women had a 100.4^oF or higher fever, if she was discharged without discharge orders, or if she was not transfused for a hematocrit less than 20%, the care was given a rating of high potential for immediate harm. If the abdominal wound was not checked before discharge, the care was rated high potential for delayed harm. Finally, the panel identified a list of adverse outcomes of hysterectomy that ranged from mild to serious, including intraoperative complications (bladder/ureteral injury, bowel injury, hypertension, myocardial infarction, stroke, cardiopulmonary arrest, death, hemorrhage, fever, and nerve injury) and postoperative complications (vaginal cuff infection or hematoma, wound complications [including return to surgery], paralytic ileus or other bowel problem, cellulitis or phlebitis, deep vein thrombosis, urinary tract infection, pneumonia; sepsis, fever, drug or transfusion reaction, fall, myocardial infarction, stroke, cardiopulmonary arrest, death, blood transfusion, postoperative anemia, or unplanned intensive care unit admission).

Statistical Analysis
We pooled the 3 states on the basis of an earlier state-specific analysis in which differences in distribution of demographics, hospital characteristics, procedures, and other factors were found but overall outcomes were similar (we corrected for state- and hospital-clustered sampling in the regression). We evaluated inappropriate hysterectomy, high potential for immediate or delayed harm (inpatient care), and postoperative complications with a bivariate analysis that compared demographics and diagnostic characteristics with quality indicator differences between Medicaid-covered women and privately insured women. Multivariable logistic regressions identified factors associated with inappropriate hysterectomy, potential immediate or delayed harmful care, and complications. For the analysis of appropriateness, we included only risk factors that preceded the surgery: age, race/ethnicity, menopausal status, diagnoses that led to hysterectomy, number of conditions, severity level of the most severe condition, whether medical treatment was attempted, previous invasive diagnostic and treatment procedures (laparoscopy, cone biopsy, cervical biopsy, colposcopy, dilatation and curettage), comorbidities, and insurance status. Hospital variables (bed size and staffing) and state of residence, age, race/ethnicity, diagnosis, severity, and insurance status were used in the inpatient care analysis. Appropriateness, possibility of harmful care, age, race/ethnicity, menopausal status, diagnoses that led to hysterectomy, number of conditions, severity of the most severe condition, whether medical treatment was attempted, previous invasive diagnostic and treatment procedures (laparoscopy, cone biopsy, cervical biopsy, colposcopy, dilatation and curettage), obesity, comorbidities, type of hysterectomy, and insurance status were tested in the analysis of complications. In both models, variables were dropped that were not statistically significantly related to the outcome. We used the quasi-likelihood method of Zeger et al.¹¹ to correct for state and hospital clustering. Beta coefficients from the models were converted to odds ratios with confidence intervals derived from variances that were corrected for cluster sampling from within hospitals and states.

	RESULTS

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The final sample size of the hysterectomy group was 2425, with 1185 Medicaid-covered women (396 from California, 380 from Georgia, and 409 from Michigan) and 1240 privately insured women (415 from California, 424 from Georgia, and 401 from Michigan). The Medicaid-covered women were disproportionately selected from public hospitals (33.7% vs 13.9%), hospitals with high Medicaid shares (73.7% vs 23.2%), teaching hospitals (43.2% vs 29%), large hospitals with more than 400 beds (42.8% vs 28.2%), and hospitals with a favorable staff-to-bed ratio (74.4% vs 67.9%) (Table 1).

Fewer Medicaid-covered women had conditions that were categorized as mild (37.6% vs 47.5%) or had medical treatment before their hysterectomy (25.5% vs 34.6%), and more Medicaid-covered women had missing data in their medical records that prevented an evaluation of severity (13.1% vs 8.4%) (Table 1). The Medicaid-covered women had more laparoscopies (17.1% vs 12.3%) and procedures related to cervical disease (cone biopsies, cervical biopsies, and colposcopies) (19.8% vs 8.2%) before their hysterectomies; however, the privately insured women had more dilation and curettage procedures (28% vs 22.4%) before their hysterectomies. More Medicaid-covered women had diabetes or were obese (8% vs 2.2% and 4.3% vs 1.5%, respectively), and the Medicaid-covered women had fewer vaginal procedures (19.2% vs 21.3%) and more radical hysterectomies (2.5% vs 0.8%).

The missing severity rating (Table 1) reduced the denominators for appropriateness to 1030 for the Medicaid sample and 1136 for the privately insured sample. There were no statistical differences by payer in either the indicator that suggested that hysterectomy was inappropriate or the indicator that inpatient care could be harmful (Table 2). However, the Medicaid-covered women developed more complications (26% vs 15.3%), including life-threatening ones (3.1% vs 1.5%), and infections (8% vs 4%). There were 4 deaths: 2 in the Medicaid group and 2 in the privately insured group.

Inappropriate hysterectomy, problems with inpatient care, and admission severity were not associated with developing a complication (Table 3). There was a 40% increase in the likelihood of developing a complication among Medicaid-covered women compared with privately insured women, a finding that was statistically significant (OR = 1.40, CI = 1.11, 1.76). More important factors associated with developing a surgical complication were having an emergency hysterectomy (OR = 28, 95% CI = 7.48, 105), having an abdominal hysterectomy (OR = 1.54, 95% CI = 1.25, 2.11), having a radical hysterectomy (OR = 3.16, 95% CI = 1.52, 6.53), or being obese (OR = 2.11, 95% CI = 1.22, 3.64). Having a diagnosis of fibroids was associated with a decrease in complications (OR = 0.73, 95% CI = 0.57, 0.92). Being African American was associated with a 68% increase in the risk for a complication (OR = 1.68, 95% CI = 1.29, 2.09); this association was independent of other risk factors in the model, i.e., the risk for an African American woman developing a complication was increased among both the Medicaid-covered women (unadjusted OR = 1.47; 95% CI = 1.10, 1.97) and the privately insured women (unadjusted OR = 1.78; 95% CI = 1.20, 2.65) (data not shown). The risk for developing a complication among Hispanic women in the cohort was elevated (OR = 1.34) but was not statistically significant. Finally, being postmenopausal was associated with developing complications (OR = 1.61, 95% CI = 1.21, 2.14). It should be noted that the effect of hospital characteristics was tested in the regression analyses and was not found to be associated with inappropriateness, problems with inpatient hospital care, or complications.

	DISCUSSION

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Our results indicate that inpatient care for Medicaid-covered women who underwent a hysterectomy was equivalent to the care provided to comparable privately insured women in this population. Despite this, the Medicaid-covered women were more likely to develop complications. The association between complications and Medicaid status persisted after we adjusted for urgency of the operation, type of procedure, race/ethnicity, and factors related to the patients’ physical condition, such as obesity or menopausal status. There were no variables in our data that explained the difference in clinical outcomes between the Medicaid-covered women and privately insured women. This included indicators of previous care, such as the receipt of previous medical treatment and previous surgical and diagnostic procedures, and receiving care that could be potentially harmful. The finding is consistent with at least 1 study that found that women who underwent a hysterectomy and who were insured by Medicaid had a 20% increase in risk for complications compared with privately insured women.¹² While there are few other studies of hysterectomy outcomes by payer group, studies of acute myocardial infarction,¹³ colon cancer,¹⁴ and breast cancer¹⁵ have shown an association between poor outcomes and payer status. More than 1 study has shown Medicaid-covered patients suffer more avoidable hospitalizations than do privately insured patients.^16,17 The reasons for these disparities are unclear. Research has hypothesized that Medicaid enrollees have problems accessing outpatient care,^18,19 perhaps because of insurance-related delays or because individuals only obtained Medicaid coverage once they became ill. In our data, we have little information about previous ambulatory care, except for the fact that the Medicaid-covered women may have had less access to noninvasive ambulatory care treatment, because fewer of them received hormonal treatment or pain medication (Table 1). However, this was not associated with complications in the regression analysis. Another possible cause of the differential complication rates is that the Medicaid-covered women may have received substandard care before the hospitalization. Again, our data do not inform this hypothesis.

There are few studies that have looked specifically at the hospital care of Medicaid patients. One study of medical injury found that Medicaid-covered patients were at increased risk for adverse events because of negligence in the operating room.²⁰ A number of studies have found that patients who underwent procedures at high-volume small hospitals or teaching hospitals had fewer complications.^21–24 Our analysis strongly hypothesizes that Medicaid-covered women received care that was equivalent to that received by the privately insured women.

We also found that being African American was independently associated with complications. This finding is consistent with 1 study of more than 53 000 hysterectomies in Maryland, where African American women were 40% more likely to develop complications, nearly 3 times as likely to have a long hospital stay, and 3 times as likely to die even though, as in our study, the African American women were younger on average.¹² African American women in our study were much more likely to have fibroids; however, having fibroids was protective in the regression analysis of complications (Table 3), which indicated that fibroids did not cause complications. Another study found that among women who underwent an abdominal hysterectomy for fibroids, those who had a uterine weight of more than 500 grams had a higher risk for complications.²⁵ However, a uterine weight under 280 grams was the only similar variable available to our analysis, and it was not statistically significant. While it is possible that African American women who have very large fibroids wait to have surgery because of limited access to covered services, our data did not allow us to evaluate this.

Although the probability of an inappropriate hysterectomy was the same for Medicaid-covered women and privately insured women, and for the White and African American women in our study, the overall rate of inappropriate hysterectomy was approximately 25%. In our study, the only factor that predicted inappropriate hysterectomy was having a diagnosis of fibroids. Forty-seven percent of the women in our study who had fibroids also had an inappropriate rating compared with 13% of those who had other diagnoses. Researchers found even more dramatic results in a study of women who underwent a hysterectomy in 3 California hospitals.²⁶ They used the Rand/UCLA method of rating appropriateness and American College of Obstetricians and Gynecologists criteria, and they found that 70% of the women had an inappropriate hysterectomy and 79% of the women who had fibroids had inappropriate surgery. The reason for this was that the recommended diagnostic steps were not done before surgery. The difference between that study and our study is that interviews were conducted and outpatient records were examined. Our appropriateness criteria were less precise because of limits in the data abstracted from medical records. The authors of the California study concluded that because there have been no clinical trials of hysterectomy effectiveness, physicians may not have objective data with which to make appropriate decisions.

There are potential limitations to the interpretation of our study results. The Rand/UCLA method used in our study was developed to assess the overuse of various medical procedures. The reproducibility of this method for judging quality of care has been called into question, particularly with conditions such as hysterectomy for which stringent evidence-based criteria are less available than for coronary revascularization.¹⁰ However, the Rand/UCLA method has been found to be internally consistent, which makes it a useful tool for benchmarking appropriateness and patient care criteria for comparison between 2 groups.²⁷

Our study made it apparent that the data collected from medical records had some problems. There were more missing data points, which were needed to construct the admission severity scores, among the Medicaid-covered women than among the privately insured. In a sensitivity analysis, we found that deleting the observations not categorized for severity in the regression model did not affect the association between admission severity and complications. That reassured us that severity was not associated with developing complications.

At the time we conducted this study, there were virtually no studies that compared the quality of specific components of inpatient care provided to Medicaid-covered and privately insured patients. These studies continue to be rare. One study showed that similar resources were expended on, and similar care was provided to, low-risk obstetric Medicaid-covered and privately insured patients.²⁸ Another study showed that the payer source did not explain differences in hospital resource use for sick infants.²⁹ There have been no comparable studies of quality of care for hysterectomy.

	CONCLUSIONS

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Our study of more than 2000 women admitted to hospitals in California, Georgia, and Michigan in 1991 found that appropriateness of hysterectomy was equivalent for Medicaid-covered women and privately insured women, as was the care the 2 groups received in the hospital. However, Medicaid-covered and African American women had higher rates of postoperative complications that were not associated with the quality of inpatient care or with the severity of condition that led to the procedure. The complications were highest among women who had an abdominal hysterectomy, which remains the most common type of hysterectomy procedure.³⁰ Because hysterectomy is the second most common surgery among women after cesarean section, disparities in outcomes after hysterectomy will lead to an increased economic burden to Medicaid.²⁹ Further studies of the racial/ethnic and sociodemographic issues are needed so that these disparities may be addressed; particularly, researchers need to determine what nonhospitalization factors are involved in the disparities found in this and other studies.

	Acknowledgments

 
This study was conducted by the MEDSTAT Group, Santa Barbara, Calif, under contract to the Centers for Medicare and Medicaid Services. The authors would like to acknowledge the clinical consultants for this project: Joseph Gambone, DO, and Anita Nelson, MD.

Human Participant Protection
Institutional review boards at each hospital in the study approved this research.

	Footnotes

 
Note. The views expressed in this study are those of the authors and do not reflect those of the US Department of Health and Human Services or the Centers for Medicare and Medicaid Services.

Contributors
R. B. Hakim analyzed the data and wrote the paper. M. B. Benedict supervised the study and contributed to the data analysis and the writing of the article. N. J. Merrick planned and directed the study and contributed to the data analysis and the writing of the article.

Peer Reviewed

Accepted for publication September 18, 2003.

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This Article Abstract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (5) Citing Articles via Google Scholar Google Scholar Articles by Hakim, R. B. Articles by Merrick, N. J. Search for Related Content PubMed PubMed Citation Articles by Hakim, R. B. Articles by Merrick, N. J. Related Collections Access to Care Quality of Care Other Health Service Delivery African Americans/Blacks Other Race/Ethnicity Women's Health