Each year in the United States, 600,000 women undergo hysterectomy, and it is the most common nonpregnancy‐related procedure performed.1,2 By the age of 60, nearly one in three women will have undergone hysterectomy.1,3 International hysterectomy rates vary, with the highest rates in the United States and the lowest rates in Norway and Sweden.4,5 There has been concern about the inappropriate overuse of hysterectomy.6,7 Furthermore, it has been reported that about 40,000 women (6.6%) who have a hysterectomy each year will fail to achieve desired results. A small but significant proportion of women who undergo hysterectomy will develop new symptoms after the hysterectomy such as pain and depression.8,9
Laparoscopically assisted vaginal hysterectomy was first introduced in the 1980s,10 and a number of advantages of this type of hysterectomy were proposed, including shorter length of stay, reduced complications, reduced hospital charges, and better surgical outcomes.11 Vaginal hysterectomy has long been a useful alternative to abdominal hysterectomy as less postoperative infection, shorter length of stays, and faster recovery time are reported.12 The hope with laparoscopically assisted vaginal hysterectomy was that it could replace some of the abdominal hysterectomy procedures that were not amenable to the vaginal approach. One study of women with relative contraindications for vaginal surgery, who were randomized to either laparoscopic hysterectomy or vaginal hysterectomy, suggested little benefit with the laparoscopic approach.13 However, in the trials of laparoscopic hysterectomy and abdominal hysterectomy, length of stay and recovery were shorter with the laparoscopic approach.14,15
The aim of this study was to assess the rates and type of hysterectomy in the United States over the years 1990–1997 and to determine the age of patients, length of stay, total hospital charges, and diagnostic category for each type of hysterectomy.
MATERIALS AND METHODS
We obtained data from the Healthcare Cost and Utilization Project, which is built and disseminated through a federal‐state‐industry partnership sponsored by the Agency for Healthcare Research and Quality.4 The Nationwide Inpatient Sample contains all discharge data from about 1000 hospitals (including university and specialty hospitals) located in 22 states, approximating a 20% stratified sample of US community hospitals from which it is possible to derive national estimates. All discharges with an International Classification of Diseases, 9th Revision, Clinical Modification (ICD‐9‐CM) code corresponding to hysterectomy for women of any age were included. There were no exclusions. Hysterectomy was defined as the presence of an ICD‐9‐CM procedure code of 68.4 for abdominal hysterectomy, 68.5, 69.51, or 68.59 for vaginal hysterectomy, 68.3 for subtotal or supracervical hysterectomy, 68.51 for laparoscopic hysterectomy, 68.6, 68.7 for radical hysterectomy, and 68.9 for other and unspecified as a primary or secondary procedure on the discharge record. The ICD‐9‐CM code for laparoscopic hysterectomy was not introduced until October 1996. Therefore, observations before this time were identified when the code for laparoscopy (ICD‐9‐CM 54.21) was used in combination with vaginal hysterectomy, subtotal, or other hysterectomy. This methodology for identifying laparoscopic hysterectomy has been used previously.16 After 1996, when the code for laparoscopy and any other hysterectomy (except abdominal or radical) occurred together, these observations were included with the total for laparoscopically assisted vaginal hysterectomy. Given that this database reflects inpatient care only, it was important to examine whether many hysterectomies were performed as ambulatory surgery procedures in 1997. Therefore, the State Ambulatory Surgery Database for New York, another component of the Healthcare Cost and Utilization Project databases, was examined for hysterectomy procedures. Only 0.1% of all hysterectomies in New York in 1997 were identified as ambulatory procedures. The Clinical Classification Software, a tool for clustering patient diagnoses into a manageable number of clinically meaningful categories, developed at the Agency for Healthcare Research and Quality, was used to define the diagnostic categories.17
Variables that were extracted included age of patients, length of stay, total hospital charges, and diagnosis. The data about race in this database were incomplete because many states do not collect race information, and although race was initially extracted and analyzed, it is not presented because of the large amount of missing data. Charges were not adjusted for inflation. Data were only available for the years 1990–1997 at the time these analyses were conducted.
Rates of hysterectomy for each year were calculated using the population of women over the age of 16 years as the denominator from US census data for each year (estimated for each year based on the 1990 census data). For each method of hysterectomy, the median age, median length of stay, and the median total charges were computed, as the data were not normally distributed. The frequency of each method of hysterectomy was calculated for grouped diagnostic codes. SAS software was used to conduct the analyses (SAS Institute Inc., Cary, NC).
For the years 1990–1997, the rates of hysterectomy in the United States have not changed substantially (Table 1). However, there has been a change in the type of hysterectomy performed. Abdominal hysterectomy is the most frequent procedure over the 8 years studied, and in 1997 represented 63% of all procedures. The frequency of abdominal hysterectomy decreased to its lowest in 1994, but then plateaued. There was a concomitant increase in laparoscopic hysterectomy, whereas abdominal hysterectomy was decreasing. Laparoscopic procedures represented 9.9% and vaginal hysterectomy 23% of all hysterectomies in 1997. There was a 30‐fold increase in the frequency of laparoscopic hysterectomy over the 8 years. Subtotal hysterectomy tripled over the 8 years studied but represented only 2% of all hysterectomies.
The median age for hysterectomy by type of hysterectomy is presented in Table 2. The median length of stay declined for each type of hysterectomy over the 8 years studied (Table 2). Laparoscopic hysterectomy had the shortest length of stay in 1990 of 3 days and by 1997 this had declined to 2 days. The median total hospital charges were the lowest in women who underwent vaginal hysterectomy for all of the years studied (Table 2). The total hospital charges for laparoscopic hysterectomy almost doubled from 1990 to 1997.
The primary diagnosis varied by type of hysterectomy, and 40% or greater of abdominal and subtotal hysterectomies were performed for fibroids (Table 3). Of women with fibroids, endometriosis, cancer, or inflammatory diseases of the pelvis as a primary diagnosis, more than two thirds underwent abdominal hysterectomy (Table 4). When uterovaginal prolapse was the primary diagnosis, vaginal hysterectomy was the most frequent procedure.
Hysterectomy rates in the United States have changed little over the 8 years reported, but have declined over the past two decades. The Centers for Disease Control National Hospital Discharge Survey reported a slight decline in rates from 1980 (7.1 hysterectomies per 1000 women) to 1987 (6.6 per 1000 women).2 The survey was redesigned in 1988, which is believed to account for lowered rates being reported (the average annual rate for 1988–1993 was 5.5 per 1000 women).2 The rates that we have reported for 1990 are very similar to those rates reported by the National Hospital Discharge Survey (5.5 per 1000 women in 1990).2 The Organization for Economic Cooperation and Development data for 1996 suggests that the US rates are three to four times higher than those in Australia, New Zealand, and most European countries.5
This report builds on and updates an earlier study using the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project.18 There is potential with all administratively collected data to contain inaccuracies especially with regard to coding of diagnoses or type of procedure. Although the total numbers of hysterectomy are likely to be robust, there is some concern that the diagnostic codes may contain inaccuracies. For example, 15% of radical hysterectomies do not appear to have cancer as an indication.
Laparoscopic hysterectomy accounted for nearly 10% of all hysterectomies performed in 1997. The appropriate proportion of hysterectomies that should be performed laparoscopically is unknown. A randomized controlled trial of vaginal hysterectomy versus laparoscopic hysterectomy among women with relative contraindications for vaginal surgery (enlarged uterus with fibroids) suggested that the majority of hysterectomies can be performed by the vaginal approach.12 A review of 34 case series reported that laparoscopic hysterectomy involved a shorter hospital stay, speedier postoperative recovery, and less analgesia use, but also a higher rate of bladder injury and longer duration of surgery.19 The results from our report show that the proportion of laparoscopic hysterectomy is not high, and the resultant decrease in numbers of abdominal procedures is appropriate.
There is much to commend vaginal hysterectomy as a method of hysterectomy for parous women without large fibroids. Vaginal hysterectomy usually takes less than hour, inpatient stays are approximately 2 days, it is associated with fewer intraoperative or postoperative complications (compared with abdominal hysterectomy), and it is less costly than either laparoscopic or abdominal hysterectomy.12–14,20 However, the number of vaginal hysterectomies over the 8 years studied has essentially remained unchanged in the United States. In 1997, less than a quarter of the hysterectomies performed in the United States were by the vaginal route, which is similar to other US reports.2 Overall, the rates of vaginal hysterectomy in the United States are lower than those reported in France and Australia where approximately 40–50% of patients undergo hysterectomy by the vaginal route.21,22
The most common diagnosis for hysterectomy in this report was leiomyoma. Leiomyomas are commonly reported among black women, accounting for 75% of hysterectomies among this ethnic group.23 The management of symptomatic uterine leiomyoma is challenging because of the paucity of clinical trials and a failure of much of the research to report long‐term clinical outcomes.23 Furthermore, little is known about the natural history of women with asymptomatic fibroids. The use of uterine artery embolization is promising, although the evaluation of this experimental procedure is limited by the lack of evidence from randomized controlled trials and the lack of follow‐up of cohorts beyond 1 year.24 Another frequent diagnosis was menstrual disorders, and there are a number of conservative surgical and nonsurgical options available to manage menstrual problems. Endometrial ablation is now widely available, and up to 75% of women will subsequently avoid hysterectomy over the 4 years after the procedure.25 If further declines in hysterectomy rates are to occur, effective treatments for managing common reproductive conditions need to be considered, and future research needs to focus on nonsurgical alternatives for fibroid management.
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© 2002 The American College of Obstetricians and Gynecologists
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