Materials and Methods
This study was determined to be exempt by the University of California, Los Angeles, Institutional Review Board. Public Use File data from 1999 through 2009 were obtained from the Centers for Medicare and Medicaid Services for a 5% random national sample of beneficiaries. The 5% cohort available for research was identified and tracked longitudinally based on the last 2 digits of the Medicare beneficiary’s health insurance claim number. Patients with POP were identified by one of several International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ) codes for prolapse during this time course. Current Procedural Terminology, 4th Edition ( CPT-4 ) and ICD-9-CM procedure codes were used to evaluate the surgical procedures performed during the same time period. The codes (listed in the Appendix ) were classified and segregated by nonsurgical (pessary) and surgical management. Surgical procedures were classified by compartment (anterior, posterior, and apical). Annual rates were determined by dividing the CPT-4 and ICD-9-CM code rates by the total number of women given a POP diagnosis that year. Combinations of codes for simultaneous compartment repairs were also assessed to capture rates of single and multiple concomitant procedures. The CPT-4 code for mesh/graft was developed in 2005 (code 57267, “insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach”), therefore the analysis of rates of mesh use apply from 2005 through 2009. Among those patients with a code for hysterectomy, a subanalysis was performed comparing rates of isolated hysterectomy for prolapse to those with a concomitant vault suspension.
Results
The analytical cohort was comprised of women age ≥65 years, who received a diagnosis of POP from 1999 through 2009. This cohort served as the denominator for the analysis ( Table 1 ). Each year an average of 22,427 women (range, 21,245–23,268) were given a POP diagnosis. Of these women, 26% received some kind of treatment for their condition each year during the study period ( Figure 1 ). Depending on the year, an average of 12% of women (range, 11–13%) were treated with a pessary. In addition, each year 14-15% of the women underwent surgical repair. These percentages remained relatively stable over the course of 11 years.
| Variable, n (%) | 1999 | 2003 | 2006 | 2009 |
|---|---|---|---|---|
| Prolapse diagnosis | 21,245 | 23,268 | 22,688 | 22,553 |
| Any prolapse treatment | 5417 (25.5) | 6280 (27) | 6089 (26.8) | 5905 (26.2) |
| Pessary | 2403 (11.3) | 3118 (13.4) | 2985 (13.2) | 2953 (13.1) |
| Any surgical treatment for prolapse | 3244 (15.3) | 3423 (14.7) | 3333 (14.7) | 3197 (14.2) |
| Colpocleisis | 115 (0.5) | 156 (0.7) | 140 (0.6) | 120 (0.5) |
| Anterior | 895 (4.2) | 1063 (4.6) | 1197 (5.3) | 1230 (5.5) |
| Anterior and apical | 2577 (12.1) | 2646 (11.4) | 2630 (11.6) | 2601 (11.5) |
| Anterior and posterior | 2747 (12.9) | 2910 (12.5) | 2851 (12.6) | 2654 (11.8) |
| Anterior and posterior and apical | 3196 (15) | 3346 (14.4) | 3256 (14.4) | 3127 (13.9) |
| Posterior | 764 (3.6) | 774 (3.3) | 835 (3.7) | 759 (3.4) |
| Posterior and apical | 2486 (11.7) | 2475 (10.6) | 2403 (10.6) | 2309 (10.2) |
| Apical a | 2172 (10.2) | 2114 (9.1) | 2054 (9.1) | 2018 (8.9) |
| Mesh | 0 | 0 | 933 (4.1) | 1306 (5.8) |
a See Table 2 for isolated hysterectomy rates.
Of those who underwent surgery, most often multiple compartments were repaired simultaneously. The most frequent combination performed was anterior, posterior, and apical repairs (14-15%), followed by a combined anterior and posterior repair (12-13%), an anterior and apical repair (11-12%), and a posterior with apical repair (10-12%), respectively. The least commonly performed repairs were colpocleisis (1%) and isolated anterior (4-6%) and posterior (3-4%) repairs.
We separately analyzed rates of hysterectomy with and without concomitant apical repairs ( Table 2 ). Over time there was a decrease in overall rates of abdominal and vaginal hysterectomies performed for prolapse. Isolated hysterectomy rates (without a concomitant apical repair) decreased from 39-28% of women who had surgery for prolapse. Specifically, vaginal hysterectomies <250 g decreased from 15.1-11.3% among those who had surgery, and rates of “vaginal hysterectomy for prolapse” ( ICD-9-CM code 68.5) and “other vaginal hysterectomy” ( ICD-9-CM code 68.59) decreased from 30.8% and 28.2% in 1999 to 19.7% and 16.9% by 2009, respectively (data not shown). The rate of concomitant vault suspension remained low throughout the time periods analyzed, although there was an increase from 22% in 1999 to 26% in 2009.
| Variable, n/% | 1999 | 2003 | 2006 | 2009 | ||||
|---|---|---|---|---|---|---|---|---|
| Isolated hysterectomy | 1253 | 38.6% | 1176 | 34.3% | 1038 | 31.1% | 885 | 27.7% |
| Combined hysterectomy and vault suspension | 347 | 10.7% | 313 | 9.1% | 350 | 10.5% | 309 | 9.7% |
| Total no. of hysterectomies | 1600 | 1489 | 1388 | 1194 | ||||
| Hysterectomies for prolapse performed with concomitant vault suspension | 22% | 21% | 25% | 26% | ||||
Rates of mesh use increased over time such that by 2009, 40.9% of patients who underwent prolapse surgery had a code for mesh/graft insertion. Specifically, of 3197 who underwent surgery that year, 1306 had a repair with mesh or graft material ( Figures 1 and 2 ). This is a large increase from 571 of 3317 women (17.2%) in 2005, the first year the mesh/graft code was implemented. The subsequent 3 years showed a successive increase in mesh/graft use, from 28% in 2006 to 31.7% in 2007 and 41.3% in 2008 ( Figure 3 ).
Results
The analytical cohort was comprised of women age ≥65 years, who received a diagnosis of POP from 1999 through 2009. This cohort served as the denominator for the analysis ( Table 1 ). Each year an average of 22,427 women (range, 21,245–23,268) were given a POP diagnosis. Of these women, 26% received some kind of treatment for their condition each year during the study period ( Figure 1 ). Depending on the year, an average of 12% of women (range, 11–13%) were treated with a pessary. In addition, each year 14-15% of the women underwent surgical repair. These percentages remained relatively stable over the course of 11 years.
| Variable, n (%) | 1999 | 2003 | 2006 | 2009 |
|---|---|---|---|---|
| Prolapse diagnosis | 21,245 | 23,268 | 22,688 | 22,553 |
| Any prolapse treatment | 5417 (25.5) | 6280 (27) | 6089 (26.8) | 5905 (26.2) |
| Pessary | 2403 (11.3) | 3118 (13.4) | 2985 (13.2) | 2953 (13.1) |
| Any surgical treatment for prolapse | 3244 (15.3) | 3423 (14.7) | 3333 (14.7) | 3197 (14.2) |
| Colpocleisis | 115 (0.5) | 156 (0.7) | 140 (0.6) | 120 (0.5) |
| Anterior | 895 (4.2) | 1063 (4.6) | 1197 (5.3) | 1230 (5.5) |
| Anterior and apical | 2577 (12.1) | 2646 (11.4) | 2630 (11.6) | 2601 (11.5) |
| Anterior and posterior | 2747 (12.9) | 2910 (12.5) | 2851 (12.6) | 2654 (11.8) |
| Anterior and posterior and apical | 3196 (15) | 3346 (14.4) | 3256 (14.4) | 3127 (13.9) |
| Posterior | 764 (3.6) | 774 (3.3) | 835 (3.7) | 759 (3.4) |
| Posterior and apical | 2486 (11.7) | 2475 (10.6) | 2403 (10.6) | 2309 (10.2) |
| Apical a | 2172 (10.2) | 2114 (9.1) | 2054 (9.1) | 2018 (8.9) |
| Mesh | 0 | 0 | 933 (4.1) | 1306 (5.8) |
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