Abstract：
Objective: To assess the appropriateness of hysterectomies performed at a large tertiary health system using the 1997 RAND appropriateness classification system and an updated algorithm. Design: We abstracted structured and unstructured data from electronic medical records on patient demographics, primary indication(s) for hysterectomy, diagnosis codes associated with the hysterectomy, previous treatments, and laboratory results. Subjects: Patients aged 18-44 years. Exposure: Receipt of hysterectomy for benign and nonobstetric conditions from October 2014 to December 2017. Main Outcome Measures: Using these data, we provided a RAND-based (dichotomous: inappropriate/appropriate) and Wright-based (3-level: inappropriate/ambiguous/appropriate) appropriateness rating and characterized missing information patterns associated with inappropriate ratings. Results: We analyzed 1,829 hysterectomies across 30 nonmutually exclusive primary indications for surgery. Nearly a third (32.8%) of surgeries had only one primary indication for surgery. Using the RAND-based classifier, 31.3% of hysterectomies were rated as appropriate and 68.7% as inappropriate. Using the Wright-based algorithm, 58.1% of hysterectomies were rated as appropriate, 15.7% as ambiguous, and 26.2% as inappropriate. Missing information on diagnostic procedures was the most common characteristic related to both RAND-based (46.1%) and Wright-based (51.2%) inappropriate ratings. Conclusions: The 1997 RAND classification lacked guidance for several contemporary indications, including gender-affirming care. RAND also has an outdated requirement for diagnostic surgeries such as laparoscopies, which have decreased in practice as diagnostic imaging has improved. Sensitivity analyses suggest that inappropriate surgeries cannot all be attributed to bias from missing electronic medical record data. Accurately documenting care delivery for benign gynecological conditions is key to ensuring quality and equity in gynecological care.
摘要：
目标：使用1997年RAND适当性分类系统和更新的算法评估在大型三级卫生系统中进行子宫切除术的适当性。设计：我们从电子病历中提取了结构化和非结构化数据，以了解患者的人口统计学，子宫切除术的主要指征，与子宫切除术相关的诊断代码，以前的治疗,和实验室结果。受试者：18-44岁的患者。暴露：2014年10月至2017年12月接受良性和非产科疾病子宫切除术。主要结果衡量标准：使用这些数据，我们提供了基于RAND(二分:不适当/适当)和基于Wright(3级:不适当/模棱两可/适当)的适当性评级,以及与不适当评级相关的特征性缺失信息模式.结果：我们分析了30种非互斥的主要手术指征中的1,829例子宫切除术。近三分之一（32.8％）的手术只有一个主要的手术指征。使用基于RAND的分类器，31.3％的子宫切除术被评为适当，68.7％被评为不适当。使用基于Wright的算法，58.1%的子宫切除术被评为适当的，15.7%为模棱两可，26.2%为不适当。缺少诊断程序的信息是与基于RAND（46.1％）和基于Wright（51.2％）的不适当评级有关的最常见特征。结论：1997年RAND分类缺乏对几种当代适应症的指导，包括性别确认护理。兰德对腹腔镜等诊断性手术也有过时的要求，随着诊断成像的改善，在实践中有所下降。敏感性分析表明，不适当的手术不能全部归因于缺少电子病历数据的偏见。准确记录良性妇科疾病的护理交付是确保妇科护理质量和公平性的关键。
