Objective: To evaluate the appropriateness of recommendations for hysterectomies done for nonemergency and non-oncologic 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.
Several studies suggested that physicians might use surgical procedures inappropriately, with some patients not receiving necessary care and others exposed to unwarranted risk.1,2 To improve the quality of patient care, there has been a concerted effort to develop guidelines and other criteria for physician practice. An equivalent effort to implement and disseminate those guidelines has been lacking.
The Agency for Health Care Policy and Research, a branch of the US Department of Health and Human Services, sponsored a series of studies to improve the process. One of those studies, the Women's Health and Hysterectomy Project, is designed to develop and disseminate recommendations for hysterectomy. We chose to focus this project on hysterectomy because it is the second most common major operation women have and there are significant concerns among researchers and the public that it might be overused.3–5 In this study, we report the appropriateness of recommendations for hysterectomies in a cohort of women at nine Southern California managed-care organizations before the dissemination of clinical recommendations on use of hysterectomy.