Inpatient Surgical Treatment Patterns: DISCUSSION

17 Nov
2009

Surgical Treatment DISCUSSION

Our research demonstrates that the number of inpatient surgical procedures for the treatment of patients with a primary diagnosis of uterine fibroids increased 18% over the five-year period from 1998-2002. These findings are consistent with the results of the Centers for Disease Control and Prevention’s hysterectomy surveillance from 1994-1999 for patients with a uterine fibroid diagnosis. It is important to note that the same study found that the rate of all hysterectomies increased from 1994-1998 at a slower rate than hysterectomies for uterine fibroids. The cause of the increase in the number of procedures for this condition cannot be determined by a database, but the change could be due to an increase in the incidence of the uterine fibroids, an increase in the number of patients diagnosed, and/or an increase in the number of patients treated in an inpatient setting with a surgical procedure. In the hysterectomy surveillance report from the Centers for Disease Control and Prevention, the authors suggest that the increase in surgical procedures for patients with uterine fibroids could be a result of changes in screening practices due to the increased availability of outpatient ultrasound and a more aggressive view toward addressing family history of uterine fibroids.

Other studies confirm that uterine fibroids are more common in black women than in white women, and they tend to develop or present at a younger age. As a result, the diagnosis and treatment of uterine fibroids is of interest to the African-American community. This study found that race played an important role in the procedures that were performed on women nationwide. For women hospitalized with a primary diagnosis of fibroids, women of all races, including blacks, were significantly less likely to be treated with a hysterectomy when compared with white women. Additionally, white women were more likely to have laparoscopically assisted procedures than other ethnic groups. Black women had the highest rate of all races to receive a SCH. Additionally, only Asians/Pacific Islanders were more likely to be treated with myomectomy compared with blacks. generic cialis soft tabs

Black women who are diagnosed at a younger age may be more likely to receive a myomectomy to preserve their fertility than white women. Qualitative research, including interviews and focus groups, indicates that some black women may have cultural beliefs about hysterectomies that could lead them to be more reluctant to undergo the procedure. One study reports that black women expressed a mistrust of physicians’ motives for recommending surgery. Another study found that black women reported that having a hysterectomy would be likely to impact their self-esteem and that black men view women unfavorably after a hysterectomy. The consensus is that black women may delay surgery until symptoms are severe. For these reasons described above, black women may prefer procedures, such as myomectomies, that do not render the patient sterile or, when hysterectomy is required, procedures that maintain the cervix, such as SCH.

Other nonclinical factors evaluated in this study that may impact treatment patterns include payer type and median income. Our study found that Medicaid patients were more likely to be treated with a hysterectomy when compared with patients with private insurance/HMO. This is consistent with a previous study, which reported that Medicaid patients had fewer vaginal procedures and more abdominal hysterectomies. This study also found that Medicaid patients are more likely to be treated emergently and may not have easy access to appropriate outpatient services before reaching a stage where surgery is necessary. Additionally, our study found that patients with a median household income (as evaluated by ZIP code) of >$45,000 per year were more likely than lower-income patients to be treated with myomectomy and less likely to receive a hysterectomy. These results appear to be consistent with socioeconomic explanations suggesting that higher hysterectomy rates are associated with lower socioeconomic and educational status women.
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The results of this study regarding regional variation are supported in other published papers as well. The northeast has consistently experienced a lower rate of hysterectomies and a higher rate of myomectomies compared with the midwest, south and western regions of the country.

HCUP-NIS provides an opportunity to describe inpatient practice patterns on a national level. While our research population and regression covariates exceed regression requirements and parameters, other factors, such as severity of illness or secondary illnesses that are not taken into account in a database evaluation, are clearly relevant. In particular, clinical data related to the size and locations of the fibroid, menopausal status of the patient, symptom severity scores and patient preference for maintaining fertility are needed to better understand the decision-making process for physicians and patients. Finally, as noted earlier, UAE, focused ultrasound, transvaginal cry-omyolysis and myolysis are being evaluated as potential treatments for uterine fibroids. However, without ICD-9 procedure codes that are specific to those procedures, they cannot be tracked in this type of study. strattera medication

This study has shown that the rate of inpatient surgical treatments for uterine fibroids has been increasing and that the use of certain procedures, such as LAVH and SCH, is increasing at a faster rate. Additionally, the use of these surgical interven­tions seems to vary widely with nonmedical variables, including race, payer, income and region. When considering the prevalence of uterine fibroids and the invasiveness of surgical treatment, additional research is needed to understand more about appropriate treatment for uterine fibroids.

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