Elsevier

Obstetrics & Gynecology

Volume 95, Issue 2, February 2000, Pages 199-205
Obstetrics & Gynecology

Original Articles
The appropriateness of recommendations for hysterectomy12,

https://doi.org/10.1016/S0029-7844(99)00519-0Get rights and content

Abstract

Objective: To evaluate the appropriateness of recommendations for hysterectomies done for nonemergency and nononcologic indications.

Methods: We assessed the appropriateness of recommendations for hysterectomy for 497 women who had the operation between August 1993 and July 1995 in one of nine capitated medical groups in Southern California. Appropriateness was assessed using two sets of criteria, the first developed by a multispecialty expert physician panel using the RAND/University of California–Los Angeles appropriateness method, and the second consisting of the ACOG criteria sets for hysterectomies. The main outcome measure was the appropriateness of recommendation for hysterectomy, based on expert panel ratings and ACOG criteria sets.

Results: The most common indications for hysterectomy were leiomyomata (60% of hysterectomies), pelvic relaxation (11%), pain (9%), and bleeding (8%). Three hundred sixty-seven (70%) of the hysterectomies did not meet the level of care recommended by the expert panel and were judged to be recommended inappropriately. ACOG criteria sets were applicable to 71 women, and 54 (76%) did not meet ACOG criteria for hysterectomy. The most common reasons recommendations for hysterectomies considered inappropriate were lack of adequate diagnostic evaluation and failure to try alternative treatments before hysterectomy.

Conclusion: Hysterectomy is often recommended for indications judged inappropriate. Patients and physicians should work together to ensure that proper diagnostic evaluation has been done and appropriate treatments considered before hysterectomy is recommended.

Section snippets

Methods

We measured appropriateness of recommendations for hysterectomy using two sets of criteria: 1) a set developed for the Women’s Health and Hysterectomy Project by an expert panel using the RAND/University of Southern California–Los Angeles appropriateness method, and 2) three recent ACOG criteria sets designed “to evaluate the appropriateness of hysterectomy.”6

The RAND appropriateness method has been well described.1, 2, 7 For this study, we reviewed the literature on hysterectomy to examine its

Results

Patients had a mean age of 46 years and a median of two children (Table 1). Two thirds were white, 14% were Hispanic, and 13% were black. More than half the women had household incomes between $31,000 and $75,000 per year. One third had prior tubal sterilization. The study physicians did 375 hysterectomies abdominally (75%), 107 vaginally (22%), and 15 vaginally with laparoscopic assistance (3%). Of the 97 physicians in the study, 30 did one of the hysterectomies, 22 did two or three, and 17

Discussion

We found that the care leading recommendations of hysterectomies in our cohort was suboptimal. Seventy percent of those cases did not meet standards of expert panel recommendations. In addition, 76% of women with conditions covered by ACOG criteria sets would have been referred for peer review because their care did not meet ACOG criteria.

Our finding that many diagnostic steps are not done before hysterectomy is not unique. In the Maine Women’s Health Study, fewer than half of women with

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      Citation Excerpt :

      In addition, the patients with symptomatic myomas as an indication for surgery did not have clear documentation as to whether symptoms were bulk symptoms or abnormal uterine bleeding secondary to myomas, which may indicate higher rates of hysterectomy for abnormal uterine bleeding than what we observed. Our study corroborates previous work suggesting the need for quality improvement efforts to prevent inappropriate hysterectomies by improving alternative treatment protocols for managing benign gynecologic conditions [1,16,17]. To implement these practice changes, the characterization of current utilization rates of alternative treatments and development of condition-specific treatment strategies are needed.

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    Funded in part by grant no. R18HS07095 from the Agency for Health Care Policy and Research, and in part by the Robert Wood Johnson Clinical Scholars Program.

    1

    The views expressed herein are those of the authors and do not necessarily reflect those of the Agency for Health Care Policy and Research or the Robert Wood Johnson Foundation.

    2

    The authors thank the members of the expert panel (Bruce Bagley, Constance Bohon, Vivian Dickerson, Karen Freund, Joseph Gambone, Frank Ling, Anne Moulton, Herbert Peterson, and Marian Swinker) for their assistance in developing the ratings, and Stanley Zinberg of ACOG for assistance with revising the criteria.

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