Are Hysterectomies Really on the Decline?



LAS VEGAS – The number of hysterectomies in the United States appears to be on the decline, despite a 10% increase in minimally invasive cases.

Based on updated surveillance data, an estimated 479,229 hysterectomies were performed in the United States in 2009, of which 24% used a laparoscopic approach.

Patrice Wendling/IMNG Medical Media

Dr. Sarah Cohen

By comparison, there were 518,828 hysterectomies in 2005, 14% of which were laparoscopic: 64% were abdominal and 22% were vaginal (Obstet. Gynecol. 2009;114:1041-8).

Whether this represents a real decline in hysterectomies is unclear, Dr. Sarah Cohen of Brigham and Women’s Hospital in Boston said at the 41st AAGL Global Congress.

The current analysis included oncologic cases, whereas the 2005 analysis looked only at gynecologic hysterectomies for benign disease.

On the other hand, both analyses are based on the Nationwide Inpatient Sample (NIS), which represents a 20% stratified random sample of discharges from all community hospitals in the United States. It is the largest national all-payer database of hospital discharges, but that’s where it stops.

"It’s possible that there are a number of nonsurgical options being offered to patients; however, I do think this also represents the increase in outpatient surgeries being offered, and the Nationwide Inpatient Sample databases aren’t able to account for those," she said. "Particularly, we may be underestimating laparoscopic and vaginal procedures that are being done in ambulatory settings."

Hysterectomy is the most common nonobstetric surgical procedure among women, with 600,000 typically cited as the annual number of procedures.

Dr. Cohen and her colleagues sought to verify this number using ICD-9 codes in the 2009 NIS – the most recent year available – to abstract information about any patient who underwent a hysterectomy during her hospitalization, including oncologic cases. Obstetric hysterectomies were excluded. The data were then weighted to give national estimates.

The mean patient age was 48 years, and the predominant indications were uterine fibroids (47%) and menstrual disorders (45%). Adnexal surgery occurred in 57% of cases.

Abdominal hysterectomy made up 58% of cases and vaginal hysterectomy 17% in the updated analysis, compared with 64% and 22% in the 2005 NIS, Dr. Cohen said.

In regression analysis, factors associated with laparoscopic surgery compared with abdominal surgery were younger age, white race, an indication of prolapse, menstrual disorder or endometriosis, living in an urban area, having a high income, having private insurance, and living in the Western United States.

When the regressions were repeated to compare laparoscopic with vaginal surgery, factors favoring the laparoscopic approach were age 40-49, black race, any nonprolapse indication, concomitant adnexal surgery, living in an urban area, having a high income, having private insurance, and living in the Northeastern United States.

Based on a systematic review of the literature, seven articles have been published in the past 5 years regarding hysterectomy surveillance, Dr. Cohen observed.

Although the NIS database may be incomplete, the bidirectional trends of falling overall numbers and rising laparoscopic procedures appear to be holding. An analysis of the 2003 NIS revealed 602,457 hysterectomies, with the abdominal route the most common at 66%, followed by the vaginal (22%) and laparoscopic (12%) routes (Obstet. Gynecol. 2007;110:1091-5).

Dr. Cohen said it’s critical to continue evaluating trends in hysterectomy performance, particularly with increasing outpatient minimally invasive procedures, and that he and his colleagues plan to incorporate state-level ambulatory surgery databases to capture outpatient procedures. They also will perform subgroup analyses of benign and oncologic cases, and look at factors associated with concomitant adnexal procedures.

Dr. Cohen reported no relevant financial disclosures.

Recommended Reading

Physician Pay Rule Contains Good and Bad News
MDedge ObGyn
What’s in the 2013 Fee Schedule? The Policy & Practice Podcast
MDedge ObGyn
Physician: Starve Thyself. Are Eating Disorders the Last Taboo in the Medical World?
MDedge ObGyn
Maryland Moves Ahead With Health Insurance Exchange
MDedge ObGyn
Does Re-Election Mean ACA Affirmation?: The Policy & Practice Podcast
MDedge ObGyn