WHAT DETERMINES THE CHOICE OF PROCEDURE IN STRESS-INCONTINENCE SURGERY - THE USE OF MULTILEVEL MODELING

The purpose of this study was to identify the determinants of choice o f surgical procedure (anterior colporrhaphy, colposuspension, or needl e suspension) to treat stress incontinence in women. We used multileve l modeling of data on 271 patients in 18 hospitals in England in 1993- 94. Patient-related factors included sociodemographic details, anatomi cal diagnosis, symptom severity, symptom impact, previous treatment, p arity, comorbidity, and general health status. Surgeon-related factors were specialty, grade, and annual volume of procedures undertaken. Ho spital teaching status was considered. Some patient-related factors we re associated with choice of procedure: women with a concomitant genit al prolapse, with a history of high parity, and with no previous nonsu rgical treatment were more likely to undergo an anterior colporrhaphy than a colposuspension or needle suspension (although this finding cou ld be confounded by surgical specialty). In addition, women were more likely to be treated by colposuspension if their surgeon specialized i n incontinence surgery (measured by annual volume of cases). Finally, being treated by needle suspension depended on there being a consultan t surgeon familiar with the procedure at the hospital attended. While choice of surgical procedure depends partly on the patient's anatomica l diagnosis, it is also dependent on the specialty of the surgeon whom she consults and the hospital that she attends. This variability, in turn, could have implications for the patient (as the relative effecti veness of the different procedures is unknown) and for the purchasers of care (as the relative cost-effectiveness of procedures is also unkn own).