The influence of geographical and clinical factors on decisions to use surgical mesh in operations for pelvic organ prolapse

Background: Surgical mesh can reinforce damaged biological structures in operations for genital organ prolapse. The first mesh products were cleared by the U.S. Food and Drug Administration in 2002. In contrast to stringent requirements for the development of pharmaceuticals, there was never a systematic scientific evaluation of mesh products. Purpose: We examined whether Swedish gynecological surgeons have transformed increasing amounts of scientific information into common learning, resulting in a convergent and consistent pattern of mesh use. Methods: Based on data from the Swedish National Quality Register of Gynecological Surgery, registered from 2010 to 2016, we examined changes in decisions to use mesh in a largely uniform group of 2864 recurrence patients operated by 455 surgeons, where surgical mesh was used in 1435 patients (50.1%). By means of logistic regression, we explained decisions to use mesh by clinical risk factors, an FDA warning, year of surgery, type of hospital, and geographical factors. Results: The use of mesh in Sweden varied extensively, by a range from 7% to 93% on county level. These disparities were maintained between the entities over time. Different groups of decision makers had drawn different conclusions from the available information. Geography was the most important parameter in explaining decisions to use mesh. Conclusion: Mounting scientific information has had no measurable impact on decision-making, and has not led to a more consistent decision pattern. Early decisions have led to obvious ‘communities of practice’ at county and region levels. Swedish surgeons, unaltered through 7 years, have made mesh decisions in a clearly biased fashion, highly influenced by geographical factors, and with no measurable change towards national consensus