Almost one in five hysterectomies for benign indications were unnecessary, based on 2013 data from 52 Michigan hospitals.
Uterine pathology reports did not match or support the indication for surgery in 18% of the 3,397 hysterectomies reviewed from the Michigan Surgical Quality Collaborative, a state-wide program to improve surgical care. In women under 40 years old, pathology did not support surgery in 38% of hysterectomies for benign indications.
Endometriosis and chronic pain were the most common reasons for unnecessary uterus removal; pathology was unsupportive of surgery in about 40% of those cases. Pathology also was unsupportive in about 14% of women with fibroid or acute uterine bleeding (AUB) and in about 20% of the remaining cases, which were mostly indicated for a blend of bleeding, pain, and other problems (Am. J. Obstet. Gynecol. 2014 Dec 23 [doi:http://dx.doi.org/10.1016/j.ajog.2014.11.031]).
Almost half of the women had no documentation in their charts that alternatives to hysterectomy were tried or even considered. Hormonal management, operative hysteroscopy, endometrial ablation, levonorgestrel intrauterine devices (IUDs), and other approaches were documented in 68% of women under 40 years old, but documentation was less likely in women over 40 years old. Alternatives approaches were more likely in women with larger uteri and in women with endometriosis, but were, overall, “underutilized,” Dr. Daniel Morgan, an associate professor of obstetrics and gynecology at the University of Michigan in Ann Arbor, and his fellow researchers concluded.
Dr. Daniel Morgan
Parity, body mass index, insurance, and common medical comorbidities did not seem to influence the use of alternatives in the study.
The researchers noted that checklists for preoperative appropriateness have been shown in previous studies to reduce the rate of benign hysterectomies, and increase the likelihood that pathology will support the reason for the operation.
The checklist approach “could help standardize treatment and ensure appropriate uterine-sparing management has been offered. The use of electronic medical records systems could potentially facilitate this type of standardization with relative ease,” the researchers wrote.
Also, the levonorgestrel IUD, “a highly effective, cost-saving intervention for women with acute uterine bleeding and pelvic pain, was considered [in] only 12%” of the Michigan cases. Increasing its use is another “important area for quality improvement and cost savings,” they added.
“We are now in the process of developing institution-specific reports ... on use of alternatives prior to hysterectomy and rates of negative pathology. It is our goal that each institution in the Collaborative will see their data and act on it accordingly. We hope that it will lead to more use (or at least consideration) of alternatives to hysterectomy and lower rates of negative pathology.”
The Michigan Surgical Quality Collaborative is funded by Blue Cross and Blue Shield of Michigan/Blue Care Network. Dr. Morgan reported no conflicts of interest.