EXECUTIVE SUMMARY
Hysterectomy is the second most common procedure performed for women in the United States. Laparotomy followed by inpatient hospitalization has been the traditional surgical approach. A recent report suggests that fewer women are opting for traditional procedures; the rate of hysterectomies in the United States dropped 12% between 2010 and 2013, figures indicate.
- In the current study, 386,226 women underwent hysterectomy between 2010 and 2013, with the rate of utilization decreasing 12.4%, from 39.9 to 35.0 hysterectomies per 10,000 women. The proportion of laparoscopic hysterectomies increased from 26.1% to 43.4%.
- The largest absolute decreases were among women younger than 55 years of age and among those with uterine fibroids, abnormal uterine bleeding, and endometriosis.
Hysterectomy is the second most common procedure performed for women in the United States. Laparotomy followed by inpatient hospitalization has been the traditional surgical approach. A recent report suggests that fewer women are opting for traditional procedures; the rate of hysterectomies in the United States dropped 12% between 2010 and 2013, figures indicate.1
However, outpatient hysterectomy may be more common with the rise of laparoscopy, say researchers at the University of Michigan, authors of the current report. Since ambulatory data often are not included in large national claims datasets, declines in inpatient hysterectomy may be due to an overall decrease in hysterectomy utilization, or a shift toward outpatient care, they say.
To analyze the use of laparoscopy and outpatient hysterectomy, researchers looked at procedures between 2010 and 2013 in the Health Care Cost Institute, a national dataset with inpatient and outpatient private insurance claims for more than 25 million women. The researchers used procedure codes to categorize surgical approaches as abdominal, laparoscopic, laparoscopic assisted vaginal, or vaginal.
Investigators found that 386,226 women underwent hysterectomy between 2010 through 2013, with the rate of utilization decreasing 12.4%, from 39.9 to 35.0 hysterectomies per 10,000 women. The largest absolute decreases were in women younger than 55 years of age and among those with uterine fibroids, abnormal uterine bleeding, and endometriosis. Figures indicate that the proportion of laparoscopic hysterectomies increased from 26.1% to 43.4%, with decreases in abdominal (38.6% to 28.3%), laparoscopic assisted vaginal (20.2% to 16.7%), and vaginal (15.1% to 11.5%) hysterectomies. Researchers report a shift from inpatient to outpatient surgery. In 2010, the inpatient and outpatient rates of hysterectomy were 26.6 and 13.3 per 10,000 women, respectively. However, by 2013, the rates were 15.4 and 19.6 per 10,000 women.1
Researchers compared the costs of inpatient and outpatient procedures. They found that in each year of analysis, the average reimbursement for outpatient procedures was 44-46% less than for similar inpatient procedures. Total payments for hysterectomy decreased 6.3%, from $823.4 million to $771.3 million, they report.1
The findings suggest that minimally invasive procedures and other alternatives now are more common than traditional hysterectomies that require a hospital stay, notes lead author Daniel Morgan, MD, clinical associate professor in the Department of Obstetrics and Gynecology at the University of Michigan Medical School and Von Voigtlander Women’s Hospital.
“Hospitals have been reporting declines in hysterectomies for some time, but we wanted to learn how big the decrease actually was and the most common way hysterectomy is performed today,” said Morgan in a press statement. “As more alternatives become available, more women seem to be choosing these other options.”
Researchers in the current study note that between 2010 and 2013, there were fewer hysterectomies among reproductive-age women and relatively stable rates among women older than 55 years of age. There was a marked decrease among the most common indications for hysterectomy in reproductive-age women, such as abnormal uterine bleeding, uterine fibroids, endometriosis, and chronic pelvic pain.
Clinicians and patients may be moving toward increased use of endometrial ablation and hormonal intrauterine devices to control bothersome abnormal bleeding and chronic pelvic pain. Such therapies have allowed many pre-menopausal women to control symptoms without resorting to invasive surgery.
The Duke Clinical Research Institute in Durham, NC, has been working with nine centers across the United States in a multi-year project to review the effectiveness of different treatment strategies for uterine fibroids. The project, a collaboration between the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality, is designed to help patients and clinicians make more informed choices about treatment options. (Read more on the project; see the March 2016 article, “Elevated testosterone levels might increase risk of uterine fibroids,” available at: http://bit.ly/2mpiwC4.)
The study focuses on developing a multi-center registry of women who have undergone surgical treatments for uterine fibroids. This COMPARE-UF (Comparing Options for Management: Patient-centered REsults for Uterine Fibroids) registry will establish the necessary infrastructure to support comparative clinical effectiveness research that is patient-centered.
Therapies to treat isolated heavy menstrual bleeding associated with fibroids include tranexamic acid, an oral antifibrinolytic agent that is taken only on the days of heavy menstrual bleeding. This approach decreases bleeding and improves quality of life with minimal side effects.3 Use of oral contraceptives or a levonorgestrel-releasing intrauterine device can decrease menstrual bleeding and provide birth control.
- Morgan DM, Kamdar NS, Swenson CW, et al. Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women. Am J Obstet Gynecol 2017; doi: 10.1016/j.ajog.2017.12.218.
- Moore BJ, Steiner CA, Davis PH, et al. Trends in hysterectomies and oophorectomies in hospital inpatient and ambulatory settings, 2005-2013: Statistical brief #214. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs 2016. Available at: http://bit.ly/2F0xB73. Accessed Feb. 16, 2018.
- Stewart EA. Clinical practice. Uterine fibroids. N Engl J Med 2015;372:1646-1655.
