02 Jan Alternatives To Hysterectomy May Be Underutilized
Medical Research: What is the background for this study? What are the main findings?
Response: Hysterectomy is the most commonly performed major gynecologic surgery in the United States. This study sought to examine how often alternative treatment is considered prior to hysterectomy for benign indications and how often pathology in the surgical specimen supports the need for hysterectomy. We utilized data from the Michigan Surgical Quality Collaborative, a statewide hospital collaborative, and limited the analysis to patients having a hysterectomy for uterine fibroids, abnormal uterine bleeding, endometriosis, and/or pelvic pain. Alternative treatment to hysterectomy was not documented prior to surgery in 38% (i.e. no documentation that the patient declined, was unable to tolerate, or failed any alternative treatment). A progesterone intrauterine device (IUD) was the least utilized form of alternative treatment, documented in only 12% of patients. In addition, nearly 1 in 5 (18.3%) had pathology reported that did not support the need for hysterectomy—i.e. the uterus was described as normal or unremarkable or only had minor amounts of pathology. Women <40 years had the highest rate of unsupportive pathology at 38%.
Medical Research: What should clinicians and patients take away from your report?
Response: Our study suggests that there are opportunities to increase the utilization of alternative treatments before hysterectomy. The American Congress of Obstetrics and Gynecology supports the use of hormonal therapy, operative hysteroscopy, endometrial ablation, and the levonorgestrel IUD for management of symptoms related to benign gynecologic conditions. Alternative treatments should be offered to patients contemplating hysterectomy so that they make an informed decision regarding surgery. This practice has the potential to empower patients, yield significant cost savings and avoid unnecessary surgery.
Medical Research: What recommendations do you have for future research as a result of this study?
Response: Research exploring how to optimize use of alternative therapy before hysterectomy is needed. An intervention such as a pre-operative checklist itemizing alternatives to hysterectomy (Hullfish et al. FPMRS 2012) has the potential to increase use of alternative treatment and to decrease the number of hysterectomies done with unsupportive pathology. In addition, understanding barriers to use of effective but less often utilized alternative treatment such as the levonorgestrel IUD is important. Finally, examining how use of alternatives to hysterectomy affect patient satisfaction is especially important as it will focus research on patient centered outcomes. These types of efforts could improve the quality of care for women potentially needing hysterectomy and could lead to significant cost savings.
Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative
Lauren E. Corona, BS, Carolyn W. Swenson, MD, Kyle H. Sheetz, MD, Gwendolyn Shelby, RN, Mitchell B. Berger, MD, PhD, Mark D. Pearlman, MD, Darrell A. Campbell Jr., MD, John O. DeLancey, MD Daniel M. Morgan, MD
American Journal of Obstetrics and Gynecology
Available online 23 December 2014