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Comparative Effectiveness of Uterine Leiomyoma Procedures Using a Large Insurance Claims Database

Borah, Bijan J., MSc, PhD; Yao, Xiaoxi, MPH, PhD; Laughlin-Tommaso, Shannon K., MD, MPH; Heien, Herbert C., MS; Stewart, Elizabeth A., MD

doi: 10.1097/AOG.0000000000002331
Contents: Original Research

OBJECTIVE: To compare risk of reintervention, long-term clinical outcomes, and health care utilization among women who have bulk symptoms from leiomyoma and who underwent the following procedures: hysterectomy, myomectomy, uterine artery embolization, and magnetic resonance-guided, focused ultrasound surgery.

METHODS: This was a retrospective analysis of administrative claims from a large U.S. commercial insurance database. Women aged 18–54 years undergoing any of the previously mentioned leiomyoma procedures between 2000 and 2013 were included. We assessed the following outcome measures: risk of reintervention between uterine-sparing procedures, risk of other surgical procedures or complications of the index procedure, 5-year health care utilization, pregnancy rates, and reproductive outcomes. Propensity score matching along with Cox proportional hazard models were used to adjust for differences in baseline characteristics between study cohorts.

RESULTS: Among the 135,522 study-eligible women with mean follow-up of 3.4 years, hysterectomy was the most common first-line procedural therapy (111,324 [82.2%]) followed by myomectomy (19,965 [14.7%]), uterine artery embolization (4,186 [3.1%]) and magnetic resonance-guided focused ultrasound surgery (47 [0.0003%]). Small but statistically significant differences were noted for uterine artery embolization and myomectomy in reintervention rate (17.1% compared with 15.0%, P=.02), subsequent hysterectomy rates (13.2% compared with 11.1%, P<.01) and subsequent complications from index procedures (18.1% compared with 24.6%, P<.001). During follow-up, women undergoing myomectomy had lower leiomyoma-related health care utilization, but had higher all-cause outpatient services. Pregnancy rates were 7.5% and 2.2% among myomectomy and uterine artery embolization cohorts, respectively (P<.001) with both cohorts having similar rates of adverse reproductive outcome (69.4%).

CONCLUSIONS: Although the overwhelming majority of women having leiomyoma with bulk symptoms underwent hysterectomy as their first treatment procedure, among those undergoing uterine-sparing index procedures, approximately one seventh had a reintervention, and one tenth ended up undergoing hysterectomy during follow-up. Compared with women undergoing myomectomy, women undergoing uterine artery embolization had a higher risk of reintervention, lower risk of subsequent complications, but similar rate of adverse reproductive outcomes.

Among women with bulk symptoms from leiomyomas who underwent myomectomy and uterine artery embolism, reintervention rates were 15.0% and 17.1%, respectively, and 11.1% and 13.2% underwent hysterectomy subsequently.

Departments of Health Sciences Research, Obstetrics and Gynecology, and Surgery and the Kern Center for Science of Health Care Delivery, Mayo Clinic, and the Departments of Obstetrics-Gynecology and Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota.

Corresponding author: Bijan J. Borah, MSc, PhD, 200 First Street SW, Rochester, MN 55905; email:

Supported by Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD060503), National Institutes of Health/National Center for Research Resources Clinical and Translational Science Awards Grant Number UL1 RR024150, and a grant from the Focused Ultrasound Foundation.

Financial Disclosure Dr. Laughlin-Tommaso has received National Institutes of Health (NIH) funding (5K12HD065987-O2) and research funding, paid to the Mayo Clinic, from Truven Health Analytics, and Insightec (Israel) for a focused ultrasound ablation clinical trial. She is on the data safety monitoring board for the ULTRA trial (Halt Medical, California). Dr. Stewart has received NIH funding (R01HD060503, P50 HS023418, R01HD074711) and served as a consultant to AbbVie, Astellas Pharma, Bayer Health Care, Gynesonics, and Viteava for consulting related to uterine leiomyoma; to GlaxoSmithKline for consulting related to adenomyosis; and to Welltwigs for consulting related to infertility. She has also received royalties from UpToDate and Massachusetts Medical Society. The other authors did not report any potential conflicts of interest.

Presented as a poster in the AcademyHealth Annual Research Meeting, June 15, 2015, Minneapolis, Minnesota.

Each author has indicated that he or she has met the journal’s requirements for authorship.

© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.