George Morgan (HCD Economics) announces publication in BMJ Open of a study investigating surgical trends, outcomes and disparities in minimal invasive surgery for patients with endometrial cancer. A retrospective cohort study undertaken by HCD Economics, led by Professor Esther Moss of University of Leicester, has recently been published in the September 2020 edition of BMJ Open, (http://dx.doi. org/10.1136/bmjopen-2019- 036222). The study objective was to examine surgical outcomes and trends in the implementation of minimally invasive surgery (MIS) use for endometrial cancer (EC).

While the benefit of minimally invasive surgery (MIS) over traditional open surgery for EC has been firmly established with non-inferiority of survival and recurrence rates, and significantly lower levels of postoperative complications, there are potential barriers to MIS in clinical practice. This study was undertaken to establish and report the association between the route of surgery (MIS vs traditional open surgery) on perioperative morbidity and mortality. The authors identify this study as a first step towards improving clinical adoption of MIS, and to encourage further research to understand the potential barriers to MIS in clinical practice.

Data were drawn from Hospital Episode Statistics (English National Health Service hospitals 2011– 2017/2018). 35,304 patients having a hysterectomy for EC were identified, upon which the HCD Economics team conducted univariate and multivariate analyses compared MIS to open hysterectomy (OH) by assessing the association between demographic, clinical and hospital characteristics by using logistic regression. A propensity score was created, to control for confounding factors including demographics, clinical and hospital characteristics, from a logistic regression which enabled the inverse probability weighting of treatment to be applied in order to compare outcomes of treatment.

The study results confirm that disparities exist in the use of MIS for the treatment of EC/ECIS in England including the observation of a significant difference seen in the perioperative outcome of the different routes of surgery. The length of hospital stay was significantly longer for OH as compared with MIS.

Limitations include the lack of cancer stage information and potential recording or adjudication errors. Confining the survival analysis to 90 days following surgery aimed to capture procedure related rather than disease-specific deaths, although since stage data are not available, it is possible some of the deaths may have been due to disease progression rather as a result of surgery.

The main strength of this study is that it is population based and the large number of procedures has enabled trends to be identified that may not have been seen in smaller datasets. HES data only covers NHS‐funded care in England, therefore, data on hysterectomies undertaken outside of the NHS were not included in this study.

The authors recommend further investigation of patient level data, preference elicitation studies and qualitative research are needed to understand the potential barriers to MIS in clinical practice and to improve access so that as many patients as possible can benefit from the reduced morbidity and mortality associated with MIS.


The full paper is available now, on-line from BMJ Open 036222

For more information on the retrospective cohort studies undertaken by HCD Economics using HES data, please contact George Morgan at HCD Economics (

For more information on research work currently in progress across a number of therapeutic areas – please contact Lesley Piltz (