Trends in management of pelvic organ prolapse among female Medicare beneficiaries




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.



Table 1

Numbers (n) and rates (%) of prolapse repairs among female Medicare beneficiaries
























































































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)

Khan. Prolapse management trends. Am J Obstet Gynecol 2015 .

a See Table 2 for isolated hysterectomy rates.




Figure 1


Prolapse diagnosis and rates of different management patterns among female Medicare beneficiaries

Khan. Prolapse management trends. Am J Obstet Gynecol 2015 .


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.



Table 2

Rates of hysterectomy and apical repairs (isolated and concomitant)










































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%

Khan. Prolapse management trends. Am J Obstet Gynecol 2015 .


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 ).




Figure 2


Rates of different types and combinations of prolapse repairs among female Medicare beneficiaries

Khan. Prolapse management trends. Am J Obstet Gynecol 2015 .



Figure 3


Rates of mesh/graft use from 2005 through 2009

Khan. Prolapse management trends. Am J Obstet Gynecol 2015 .




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.



Table 1

Numbers (n) and rates (%) of prolapse repairs among female Medicare beneficiaries
























































































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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May 6, 2017 | Posted by in GYNECOLOGY | Comments Off on Trends in management of pelvic organ prolapse among female Medicare beneficiaries

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