The impact of re-adoption of open radical hysterectomy on postoperative outcomes in the United States: An interrupted time series analysis.

Abstract

5538 Background: The Laparoscopic Approach to Cervical Cancer (LACC) trial, published in 2018, demonstrated inferior disease-free and overall survival outcomes with minimally invasive radical hysterectomy compared to open surgery for cervical cancer, establishing open radical hysterectomy (ORH) as the standard of care. This study evaluates the impact of the rapid adoption of ORH after publication of the LACC trial on postoperative outcomes. Methods: We categorized 2013-2017 as the pre- LACC period, 2019-2022 as the post -LACC period, and 2018 as the washout period. We included patients who underwent radical hysterectomy for cervical cancer in a Commission on Cancer-accredited program with the highest utilization of ORH (top quartile, > 83%) in the post-LACC period. We fit linear probability models with cluster-robust standard errors to estimate the causal association between ORH adoption, postoperative length of stay, 30-day readmission rates, and 90-day mortality, using pre-LACC trends to estimate a counterfactual outcome for 2019 and comparing these with outcomes from the post-LACC period. Results: 2,982 patients were treated in the 107 rapid adopter hospitals. Mean age was 46.5 (SD 12). Most patients were white (67%), followed by Hispanic (14%), and Black (11%). Most patients had grade 1 or 2 (60%) tumors with squamous cell (52%) or adenocarcinoma (40%) histology. Thirty-two percent of patients had positive LVSI and 12% of patients had positive lymph nodes. The proportion or ORH was 45% vs 94% in the pre- vs post-period and ORH utilization was 65 percentage points (p.p.) higher than the estimated 2019 counterfactual ORH utilization. In the pre-period, MIS use increased significantly over time (4.1 p.p. per year, 95% CI 1.9-6.3, p < 0.001) while mean length of postoperative stay declined (0.3 days per year, 95% CI 0.1-0.5, p = 0.003). Rapid adoption of ORH in 2019 (+65.1 p.p., 95% CI 53.4-76.8, p < 0.001) was associated with a 1.7 day (95% CI 1.0-2.5, p < 0.001) increase in the duration of postoperative hospitalization, from 1.5 to 3.3 days. There was no significant association with a change in 30-day readmission rates (3.6% pre vs 1.9% post, 1.7 p.p. decrease, 95% CI -5.3 to +1.8, p = 0.35). Only 13 patients (0.4%) died within 90 days of surgery over the entire study period, precluding analysis of postoperative mortality. Conclusions: Rapid adoption of ORH following the LACC trial was associated with a moderate increase in postoperative length of stay, but no change in 30-day readmission rate.