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Hysterectomy Pathway as the 
Global Engine of Practice Change: 
Implications for Value in Care 

Amin Sanei-Moghaddam1, Sharon 
Goughnour1, Robert Edwards2, 
John Comerci2, Joseph Kelley2, 
Nicole Donnellan3, Faina Linkov1, 
Suketu Mansuria3 
 
1Magee-Womens Research Institute, 
Department of Obstetrics, Gynecology 
and Reproductive Sciences; 
2Division of Gynecologic Oncology, 
Department of Obstetrics, Gynecology 
and Reproductive Sciences, University of 
Pittsburgh Medical Center, Magee-
Womens Hospital; 
3Divisions of Minimally Invasive 
Gynecologic Surgery, Department of 
Obstetrics, Gynecology and Reproductive 
Sciences, University of Pittsburgh 
Medical Center, Magee-Womens Hospital 

 
Vol. 6, No. 1 (2017)   |   ISSN 2166-7403 (online)  
DOI 10.5195/cajgh.2017.299 |   http://cajgh.pitt.edu 

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Abstract 

Introduction: In 2012, University of Pittsburgh Medical Center (UPMC) introduced a hysterectomy clinical pathway to reduce 
the number of total abdominal hysterectomies performed for benign gynecological indications. This study focused on exploring 
physician and patient factors impacting the utilization of hysterectomy clinical pathways.  
Methods: An online survey with 24 questions was implemented to explore physicians’ attitudes and perceived barriers toward 
implementing the pathway. A survey consisting of 27 questions was developed for patients to determine the utility of a pathway-
based educational tool for making surgery decisions and to measure satisfaction with the information provided.  Descriptive 
statistics were used to describe survey results, while thematic analysis was performed on verbal feedback submitted by 
respondents.   
Results: Physician respondents found the clinical pathway to be practical, beneficial to patients, and up-to-date with the latest 
evidence-based literature. Key barriers to the use of the pathway that were identified by physicians included perceived waste of 
time, inappropriateness for some of the patient groups, improper incentive structure, and excessive bureaucracy surrounding the 
process.  Overall, patient respondents were satisfied with the tool and found it to be helpful with the decision-making process of 
choosing a hysterectomy route.   
Conclusions: Physicians and patients found the developed tools to be practical and beneficial. Findings of this study will help to 
use pathways as a unifying framework to shape future care of patients needing hysterectomy and add value to their care. 

Keywords: Clinical Pathways; Hysterectomy; Decision Support Tools; Survey Research  

Hysterectomy Pathway as the Global 
Engine of Practice Change: 
Implications for Value in Care 

Amin Sanei-Moghaddam1, Sharon 
Goughnour1, Robert Edwards2, John 
Comerci2, Joseph Kelley2, Nicole 
Donnellan3, Faina Linkov1, Suketu 
Mansuria3 
 
1Magee-Womens Research Institute, Department of 
Obstetrics, Gynecology and Reproductive Sciences; 
2Division of Gynecologic Oncology, Department of 
Obstetrics, Gynecology and Reproductive Sciences, 
University of Pittsburgh Medical Center, Magee-Womens 
Hospital; 
3Divisions of Minimally Invasive Gynecologic Surgery, 
Department of Obstetrics, Gynecology and 
Reproductive Sciences, University of Pittsburgh Medical 
Center, Magee-Womens Hospital 

Research 

Hysterectomy is one of the most common 
gynecologic procedures in the US, with approximately 
600,000 women undergoing a hysterectomy each year.1-

3 Hysterectomy is a common procedure used to treat 
endometrial cancer, the most common gynecologic 
malignancy in the US women.  Published evidence 
points to the excessive use of open surgical approaches 
for hysterectomy when minimally invasive approaches 
may be used.4 Reducing the overutilization of open 
hysterectomy has many benefits: lessening patient 
recovery time, reducing surgical complications, such as 
infection and thromboembolic events, and decreased 
healthcare expenditures.4-7 One way of reducing this 
variability in care is by adopting clinical pathways. 

Clinical pathways became an essential part of 
patient care management in the US. By the late 1990s, 
more than 80% of US hospitals used at least some 
clinical pathways to manage patient care.8 Clinical 

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pathways are evidence-based, multidisciplinary care 
algorithms that outline essential steps in the medical 
management of a specific clinical condition.9 A recent 
study by Hripcsak et al. characterized treatment 
pathways on a global scale and found that the pathways 
improved consistency of therapy across diseases and 
locations.10  

In 2012, University of Pittsburgh Medical 
Center (UPMC) introduced a hysterectomy clinical 
pathway to reduce the number of total abdominal 
hysterectomies being performed for benign 
gynecological indications.4,11 We hypothesized that 
pathways could be a unifying vehicle of change for both 
providers and patients in choosing the most optimal 
surgical approach to hysterectomy, which can have very 
important implications for gynecologic care and 
healthcare in general. The first aim of this study was to 
examine physicians’ perceptions and attitudes toward 
utilization of the hysterectomy clinical pathway 3 years 
after its implementation.   

The second aim of this study was to investigate 
if a “pathways-oriented” patient education tool would 
be helpful for patient decision-making. Patients do not 
always have an effective decision support infrastructure 
when it comes to making decisions about which 
hysterectomy route is the best for them.  Additionally, 
physicians and other healthcare providers may not 
necessarily have the time to go into the details of all 
surgical options. To fill this gap, our group sought to 
develop and introduce a hysterectomy pathway 
informed online educational tool for patients 
considering elective hysterectomy, and pilot this effort 
in UPMC facilities. By using the internet to educate 
patients about various hysterectomy types/routes, we are 
employing technology that is already used by many 
women to obtain health information. By empowering a 
larger number of women to opt for minimally invasive 
surgery at specialized centers, we can potentially 
improve patients’ clinical outcomes by reducing adverse 
outcomes associated with open procedures, while also 

controlling costs associated with hospital stay that can 
be reduced by roughly 1.5 days4. We hypothesized that 
using this innovative online educational tool will 
encourage patients to be active partners in selecting 
hysterectomy route that works best for each individual 
woman. Thus, following the implementation of 
physician satisfaction survey, we surveyed patients on 
the utility of a pathways-based educational tool in the 
decision-making process when choosing a hysterectomy 
route.  

 

Methods 

Physician Survey 

An online survey with 24 questions for 
physicians was designed based on the review of the 
literature12-14 and local experts’ opinions to explore 
surgeons’ attitudes and perceived barriers toward 
implementing the clinical pathway. Ninety-two 
gynecologic surgeons who were exposed to the pathway 
were identified in the UPMC system by utilizing UPMC 
Healthplan data. In December 2015, an invitation email 
along with a link to the survey was sent to academic 
email accounts of all physicians utilizing pathways. This 
was an anonymous survey, and no identifiable 
information was collected. The first item on the survey 
was informed consent. The survey was distributed using 
the Qualtrics platform (Qualtrics Labs, Provo, UT). 
Qualtrics protocols were followed to minimize the risk 
of emails being trapped in spam folders.15 Reminders 
were sent at two weeks and four weeks after the initial 
invitation to those who either did not open the survey or 
did not finish the survey. Two weeks after the second 
reminder was sent the survey was closed. 
Demographics, education and training, practice 
characteristics (including number of hysterectomies 
performed in a typical month by route of surgery), and 
their opinions on different aspects of the pathway (using 
Linkert-type ranking questions where a score of 1 
indicated a favorable attitude and score of 5 indicated an 

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unfavorable attitude) were collected. This study was 
approved by the University of Pittsburgh Institutional 
Review Board (#PRO15060194).  

Patient Survey 

For the patient educational tool, we solicited 
the input from the hysterectomy pathway algorithm, 
from healthcare providers, and materials from the 
Healthwise12 website to develop the hysterectomy 
pathway informed decision making tool. The package 
explained the different types of hysterectomy 
procedures, benefits and complications associated with 
each type of hysterectomy procedure, as well as links to 
pictures and videos designed to illustrate the nature of 
the procedures.  

With the help of clinical providers and 
researchers, we developed a patient survey consisting of 
27 questions to determine the utility of this pathways 
based educational tool from the patient prospective. The 
survey was administered using the University of 
Pittsburgh Qualtrics survey software site and 
ascertained their thoughts regarding the utility of the 
site, ease of use, likes and dislikes pertaining to the site, 
and suggestions for additions and improvements.13 
Approval to conduct this research survey study was 
obtained from the University of Pittsburgh Internal 
Review Board (IRB #PRO16020590).  

Study population 

Direct recruitment of study participants was 
conducted during their visits to gynecologic surgical 
specialists. Participants were identified by the clinical 
co-investigators of this study based on the criterion of 
them considering hysterectomy for benign indications 
(either currently or in the past). We recruited 20 women 
from the Gynecology Specialties Clinic at Magee-
Womens Hospital of the UPMC Health System. When 
the patient agreed to participate and verbal consent was 
obtained, the experimental educational package and 
research survey were presented to her in the same room 
as her visit or in the consult room of the clinic (as 

appropriate based on clinic flow). Participants were able 
to review materials at their own pace and fill out the 
survey if/when they felt ready to fill it out. The 
participants were given the option of filling out the 
survey on an iPad or using a paper version. The survey 
answers were stored in a password protected electronic 
format on a secure University of Pittsburgh server and 
all responses remained anonymous. 

Data analysis 

This was a mixed methods study consisting of 
quantitative and qualitative analyses. Descriptive 
statistics were used to describe the characteristics of 
both the physician and patient survey populations. We 
conducted a thematic analysis on all verbal feedback by 
coding the key points and categorizing them into 
concepts, sub-themes, and themes.14 Two authors coded 
and categorized key themes/concepts individually and 
then with the help of a third author we aggregated the 
two sets of codes and developed the final coding 
scheme. Statistical analyses were carried out using SAS 
version 9.4 (SAS Institute, Inc., Carey, NC). 

 

Results 

Physician Survey 

All survey invitations to physicians were 
successfully delivered to the recipients’ email addresses. 
Out of 92 identified surgeons, 26 (28.2 %) started the 
online survey and 22 (23.9%) completed the survey. 
The mean age of respondents was 46.6 years (standard 
deviation 8.8) and 50% were female. Half of the 
respondents (11) finished their residency after the year 
2000 and the rest (11) finished before or during the year 
2000. Ten physicians (45.5%) had fellowship training. 

The respondents reported performing as many 
as 25 and as low as 0 (only 1 observation) 
hysterectomies in a typical month (median = 7.5). On 
average, in a typical month, the respondents performed 
185 hysterectomies (group data). One respondent 

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reported zero number of hysterectomies. Only one of 
the remaining 21 respondents reported performing a low 
volume of minimally invasive hysterectomies (MIH) 
(<30%). Laparoscopic surgery was the most common 
route of surgery with 120 cases (64.8%) followed by 
vaginal 34 (18.3%), robotic 19 (10.2%), and abdominal 
12 (6.4%) routes.  All of the respondents unanimously 
reported the positive benefits of minimally invasive 
approaches for women that are appropriate candidates 
for MIH. One respondent commented that the benefits 
of MIH are so positive that they are willing to refer to 
another physician to ensure the patient has the 
minimally invasive option.  When asked whether they 
believe they need to do more MIH, two respondents 
(one with no hysterectomies and the one with low MIH 
volume) answered yes. The remaining respondents 
believe they perform an appropriate number of MIH. 
While overall perception of pathways was favorable, 
three respondents (13.64%) had either “unfavorable” or 
“very unfavorable” attitude toward the pathway, and 7 
(31.8%) found it “unhelpful” or “very unhelpful” in 
decision making (Table 1). One respondent reported the 
pathway as “difficult to follow” and 2 respondents 
reported that the software interface was “not user-
friendly”. Overall, 19 respondents (86.36%) believed 
the clinical pathway was up-to-date with the latest 
evidence-based literature, while 17 respondents 
(77.27%) would recommend it to their colleagues. None 
of the respondents reported any resistance from the 
patients when MIH was offered to them. Lastly, when 
asked what route of surgery they would prefer should 
they or an immediate family member (spouse, mother, 
sister, or daughter) need a hysterectomy for a benign 
indication, all of them chose MIH. Thirteen respondents 
(59.09%) preferred vaginal approach, followed by 
laparoscopic route (27.27), and robotic route (13.64%).  

The three main themes that emerged during the 
analysis of verbal feedback are practice pattern, barriers, 
and benefits.  The key barriers to use of pathways 
reported by the respondents included: not being 
appropriate for all cases, perceived waste of time, 

forgetting to use it, improper incentive structure, and 
excess bureaucracy around the process.  

Patient Survey 

We surveyed 20 women who visited the 
Gynecology Specialties Clinic at Magee-Womens 
Hospital of the UPMC Health System between May 5, 
2016 and June 1, 2016. Fifteen (75%) were Caucasian, 4 
(20%) were African-American, and 1 (5%) was 
Hispanic. The average age of the thirteen women who 
reported their age, was 46 years old (standard deviation: 
7.3). 

Out of 18 participants who were considering 
having a hysterectomy, 6 reported “fibroids” as their 
chief complaint, 3 reported “heavy periods, 5 had 
“painful periods, endometriosis,” 2 had “ovarian cysts,” 
1 was BRCA mutation positive, and 1 did not specify 
her compliant. When asked whether they found the 
information on the website helpful, 12 out of 18 
(66.6%) answered “definitely yes”, 5 (27.7%) answered 
“probably yes” and 1 (5.5%) answered “might or might 
not”. 

All participants were asked to rank the source 
of information they relied on the most in making the 
decision about the type of surgery. Seventeen (85%) 
ranked physicians as their primary source, while the 
other 3 ranked the internet, family member or friends as 
their primary sources. They were also asked to rank the 
main factors that can influence their decision on 
choosing the type of surgery. Fourteen (70%) ranked 
“effectiveness in symptoms relief” as the first factor, 2 
(10%) ranked “complications”, 1 (5%) ranked “cost”, 1 
(5%) ranked “length of stay in the hospital”, 1 (5%) 
ranked “pain”, and 1 (5%) ranked “incision size”. When 
asked who was the main decision maker for the type of 
surgery, 2 (10%) said it was a shared decision between 
the primary care physician and the obstetrics and 
gynecology specialist. Twelve (60%) said this was a 
decision that should be made by the obstetrics and 
gynecology specialist. Four (20%) said they themselves 

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Overall attitude towards clinical hysterectomy 
pathways 

Number Percent 

Very favorable 4 18.18% 
Favorable 12 54.55% 
Neutral 3 13.64% 
Unfavorable 2 9.09% 
Very unfavorable 1 4.55% 

Helpfulness of  the hysterectomy pathway in 
decision making 

  

Very helpful 3 13.64% 
Helpful 0 0% 
Neutral 12 54.55% 
Unhelpful 4 18.18% 
Very Unhelpful 3 13.64% 

Practicality of the pathway in their health care 
facility? 

  

Very practical 5 22.73% 
Practical 8 36.36% 
Neutral 6 27.27% 
Impractical 1 4.55% 
Very impractical 2 9.09% 

Easy to follow   
Very easy 10 45.45% 
Easy 8 36.36% 
Neutral 3 13.64% 
Difficult 1 4.55% 
Very difficult 0 0% 

Software interface “user-friendliness”   
Very user-friendly 2 9.09% 
User-friendly 14 63.64% 
Neutral 4 18.18% 
Not user-friendly 1 4.55% 
Not user-friendly at all 1 4.55% 

Being up-to-date with the evidence-based 
literature? 

  

Yes 19 86.36% 
No 3 13.64% 

Whether the pathway changed the way they 
practice? 

  

Yes 3 13.64% 

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No 19 86.36% 
Whether they would recommend the 
hysterectomy pathway to their colleagues? 

  

Yes 17 77.27% 
No 5 22.73% 

Whether the pathway is applicable to their 
patients’ pool? 

  

Yes 11 50% 
Not sure 3 13.64% 
No 8 36.36% 

Perceived barriers to the use of the pathway   
It is very time consuming 0 0% 
Needs lot of effort 1 4.55% 
I am not sure if that is helpful 8 36.36% 
Others 13 59.09 

Table 1. Respondents’ evaluation of the clinical hysterectomy pathway 

are the ones who should make the final decision, and 2 
(10%) said it should be a shared decision between them 
and their obstetrics and gynecology specialist.   

Participants were also asked to report what 
they liked and disliked about the educational materials. 
Twelve (60%) believed it was “easy to follow,” 16 
(80%) liked the “comprehensiveness of the material”, 
and 11 (55%) believed that the links and picture were 
informative. Of all participants, only one believed the 
content was “hard to understand.” No one thought that 
the material was either “too much information,” or “too 
little information”. On the scale of 1-10 (1 = very little, 
10 =very much), participants were asked to rank 
whether a) the content was explained clearly, b) the 
presented information were new to them, and c) there 
was any discrepancy between what they read in the 
provided material and what they already knew. The 
average scores for the questions above were 9.15, 4.5, 
and 7.3, respectively.  

 Suggestions for improvements included: 
“including more pictures,” “testimonials from patients 
undergoing each type of surgery,” “videos from real 
procedures,” “explaining the difference between partial 

and total hysterectomy,” and “explaining the indications 
for bilateral salpingo-oophorectomy” were the main 
comments. 

 
Discussion 

Physicians and patients found the developed 
tools to be practical and beneficial.  This study is very 
innovative in capturing both patients and providers in 
the exploration of how pathway-based systems can fuel 
change in the way hysterectomy decisions are 
approached. This approach can have significant 
implications for changes in practice for patients 
considering hysterectomy locally and globally.  

The majority of physicians believed that the 
material is up-to-date and consistent with evidence-
based medicine, and reported that they would 
recommend it to their colleagues. However, when they 
were asked whether the pathway has changed their 
practice, 19 answered “no”. The reason behind this 
discrepancy is the fact that 20 out of 22 respondents 
(90.9%) were already practicing a high volume (>30%) 
of MIH. Therefore, it appears that there is a 
considerable self-selection bias in our sample, since 

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only those physicians who were already pro-MIH opted 
in and completed the survey. The above findings 
suggest that the respondents overall found the pathway 
to be adequate for their educational purposes. There was 
even a suggestion to integrate extra-uterine conditions 
such as ovarian cyst and endometriosis into the 
pathway. Moreover, lack of awareness about the 
presence of the pathway was not an issue since the 
pathway was mandatory in the UPMC system. 
Regarding the software interface, 95.45% of the 
physicians reported that the software is easy to navigate 
and is user-friendly or were neutral. All respondents 
agreed that using the pathway did not affect their own 
workflow, while interestingly they reported that it could 
be potentially perceived as a barrier.  

The main limitations of the physician 
component of the study are the low response rate 
(23.9%) and self-selection bias. We only heard from 1 
physician with a low MIH volume, and this is the 
population on whom we should focus more and try to 
actively engage. This makes it difficult to address this 
population’s concerns about the pathway in the future. 
The small sample size and homogeneity of the 
respondents did not allow us to run any inferential 
statistics; however, the respondents formed a balanced 
sample regarding age, gender, and training. Being a 
mixed methods study (partially qualitative and partially 
quantitative in nature), this research provided an insight 
into the gynecology surgeons’ attitudes towards a 
clinical pathway and how pathways might engineer 
practice change. However, quantitative studies are 
needed in future to parse out all the factors we identified 
in this study.  

When patients are considering a hysterectomy 
for a benign condition, deciding on the route of surgery 
is commonly an overwhelming task for the patient, 
considering the plethora of surgical approaches 
available. Our future studies will also focus on 
exploring decision support options for patients 
considering non-surgical management, as well as 

evaluate decisions that patients with malignancies are 
facing. This study represents evaluation of one of the 
first pathway based decision tool kits developed to assist 
patients in making these difficult decisions. Overall, the 
educational materials were very well received by the 
participants. We will continue to build on our current 
experience and improve the materials based on the 
comments we received from participants. 

Decision support systems, including computer 
programs designed to assist in the visualization of 
tradeoffs inherent in the decision-making process, are 
needed to educate patients more effectively and help 
them make a fully informed decision based on evidence-
based approaches. Decision support tools have been 
shown to help healthcare providers and patients make 
more informed decisions, especially when multiple 
treatment options are available with various degrees of 
risks and benefits.15,16 However, they have rarely been 
used for hysterectomy decision making. This shared 
decision making pathway informed model is especially 
important for hysterectomy, where multiple 
approaches/techniques are available.  

Clinical pathways are an effective instrument 
to decrease undesired practice variability, improve 
clinician performance, and provide consistent therapy 
for diseases on a global scale.10,17 The pathway systems 
could become a driver of change in clinical practice in 
the US and around the world, influencing both the 
patient and provider side of healthcare. In addition, 
clinical pathways can serve as a framework for moving 
forward and increasing the efficiency of care while 
decreasing the variation in care. 

 

Acknowledgements 

Supported by the Beckwith Institute’s Bench at the Bedside 

Program.   
 

 

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References  
1. CDC. Inpatient Surgery. CDC/National Center 

for Health Statistics.  
http://www.cdc.gov/nchs/fastats/inpatient-
surgery.htm. Accessed September 24, 2017. 

2. Wright JD, Herzog TJ, Tsui J, et al. 
Nationwide trends in the performance of 
inpatient hysterectomy in the United States. 
Obstet Gynecol. 2013;122(2 Pt 1):233-241. 

3. Wu JM, Wechter ME, Geller EJ, Nguyen TV, 
Visco AG. Hysterectomy rates in the United 
States, 2003. Obstet Gynecol. 
2007;110(5):1091-1095. 

4. Sanei-Moghaddam A, Ma T, Goughnour SL, et 
al. Changes in Hysterectomy Trends After the 
Implementation of a Clinical Pathway. 
Obstetrics and gynecology. 2016;127(1):139-
147. 

5. Gandaglia G, Ghani KR, Sood A, et al. Effect 
of minimally invasive surgery on the risk for 
surgical site infections: results from the 
National Surgical Quality Improvement 
Program (NSQIP) Database. JAMA Surg. 
2014;149(10):1039-1044. 

6. AAGL. AAGL position statement: route of 
hysterectomy to treat benign uterine disease. J 
Minim Invasive Gynecol. 2011;18(1):1-3. 

7. ACOG. ACOG Committee Opinion No. 444: 
choosing the route of hysterectomy for benign 
disease. Obstet Gynecol. 2009;114(5):1156-
1158. 

8. Pearson S. Et tu, critical pathways? Am J Med. 
1999;107:397-398. 

9. Rotter T, Kinsman L, James E, et al. Clinical 
pathways: effects on professional practice, 

patient outcomes, length of stay and hospital 
costs. The Cochrane database of systematic 
reviews. 2010(3):Cd006632. 

10. Hripcsak G, Ryan PB, Duke JD, et al. 
Characterizing treatment pathways at scale 
using the OHDSI network. Proc Natl Acad Sci 
U S A. 2016;113(27):7329-7336. 

11. Mansuria SM CJ, Edwards R, Sanei 
Moghaddam A, Ma T, Linkov F. Changes in 
Hysterectomy Trends and Patient Outcomes 
Following the Implementation of a Clinical 
Pathway. Obstet Gynecol. 2016;127:1-3s. 

12. Healthwise Incorporated. 2016; 
http://www.healthwise.org/about.aspx. 
Accessed September 24, 2017. 

13. Qualtrics Survey Service. 2015; 
http://technology.pitt.edu/service/qualtrics-
survey-service. Accessed September 24, 2017. 

14. Braun V, Clarke, V. Using thematic analysis in 
psychology. Qual Res Psychol. 2006;3:77-101. 

15. O'Connor AM, Tugwell P, Wells GA, et al. A 
decision aid for women considering hormone 
therapy after menopause: decision support 
framework and evaluation. Patient Educ 
Couns. 1998;33(3):267-279. 

16. Tariman JD, Berry DL, Cochrane B, 
Doorenbos A, Schepp K. Preferred and actual 
participation roles during health care decision 
making in persons with cancer: a systematic 
review. Ann Oncol. 2010;21(6):1145-1151. 

17. Lenz R, Blaser R, Beyer M, et al. IT support 
for clinical pathways--lessons learned. Int J 
Med Inform. 2007;76 Suppl 3:S397-402. 

 

 

  

 

 

 

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	Hysterectomy Pathway as the Global Engine of Practice Change: Implications for Value in Care
	Abstract
	Keywords: Clinical Pathways; Hysterectomy; Decision Support Tools; Survey Research
	Hysterectomy Pathway as the Global Engine of Practice Change: Implications for Value in Care
	Research

