Uptake and outcomes associated with outpatient hysterectomy in Ontario, Canada.

Abstract

Hysterectomy is the second most common procedure performed among women and is increasingly being performed using minimally invasive techniques. In the present study, we examine the uptake of outpatient hysterectomy in the Ontario population. We performed a retrospective population-based cohort study using administrative databases for all elective hysterectomies performed in Ontario, Canada between 2010 and 2024. We estimated the percent of outpatients admitted and compare outpatients with inpatients on 90-day readmissions, 6-month complications, and 30-day perioperative health system costs. We used logistic regression to evaluate factors associated with outpatient setting. To evaluate the association of outpatient setting on outcomes, we used propensity weighting. After exclusions, a total of 228,934 patients were included. The number of hysterectomies decreased from 16,484 in FY2010/11 to 14,748 in 2019/20, followed by a sharper decline during the COVID-19 pandemic and a recovery by FY2024/25 with 16,195 procedures performed. The proportion (and number) of hysterectomies performed in the outpatient setting increased since 2010, reaching 38% by FY2024/25. Since 2021, of the 18,281 procedures with outpatient intent, 15,743 (86%) were completed as outpatient and the remaining 2,538 (14%) were subsequently admitted on the procedure date. Outpatients were younger, healthier, received surgery earlier in the day, required less operating time, received total laparoscopic-assisted vaginal hysterectomy (67% versus 27% for inpatients) or a total laparoscopic hysterectomy (26% versus 15% for inpatients), and were completed by female surgeons and surgeons with greater experience (p<0.0001 for all). There was substantial regional variation on the provision of outpatient hysterectomy, ranging from 0% to 100% across hospitals and surgeons. Outpatients were less likely to be re-admitted within 90 days of surgery (readmissions: 676 (3.6%) outpatients vs 2076 (5.4%) inpatients; adjusted risk ratio 0.83 (95% confidence interval 0.74-0.93), p=0.0009). Between surgery and 30-days post-operatively, outpatient hysterectomy cost the healthcare system $2,546 less than inpatients. There has been a significant uptake of outpatient hysterectomy in Ontario since 2010 with close to 40% of cases being performed as day surgery, with reassuring clinical outcomes and lower health system costs.