Abstract
INTRODUCTION: Heavy menstrual bleeding (HMB) affects a quarter of all women, with half having no structural cause. Dutch guidelines recommend a stepped care approach to the management of such idiopathic HMB, starting with medication or a levonorgestrel-releasing intrauterine device (LNG-IUD), before progressing to endometrial ablation, and ultimately, hysterectomy. However, practice variation between hospitals could lead to suboptimal health outcomes and increased healthcare costs for some women.
OBJECTIVES: To evaluate adherence to stepped care for women with idiopathic HMB and to identify practice variation among Dutch hospitals.
STUDY DESIGN: This population-based cross-sectional study used Dutch insurance claims data from primary and secondary care for all women with idiopathic HMB referred to a gynecologist between January 2019 and December 2020. We calculated the average number of treatments in the 3 years before each treatment step at each hospital, making adjustments for age, socioeconomic status, and ethnicity. Variation in medical practice was measured by the coefficient of variation (CV).
RESULTS: We studied 20,715 women treated with LNG-IUDs (56%), endometrial ablation (36%), laparoscopic hysterectomy (13%), or vaginal hysterectomy (4%) in 93 hospitals. Before endometrial ablation, on average 47% used medication (hospital range 27%-71%; CV 0.17) and 16% used an LNG-IUD (hospital range 8%-29%, CV 0.32). Before hysterectomy, 52% (hospital range 28%-65%, CV 0.16) used medication, 21% (hospital range 6%-38%, CV 0.35) used an LNG-IUD, and 23% underwent endometrial ablation (hospital range 0%-59%, CV 0.55). On average, women underwent 0.63 (hospital range 0.36-1.00, adjusted rate 0.40-0.98, CV 0.17) and 0.96 (hospital range 0.56-1.45, adjusted rate 0.56-1.44, CV 0.18) treatments before endometrial ablation and hysterectomy, respectively.
CONCLUSIONS: Considerable practice variation exists among Dutch hospitals in the stepped care approach to idiopathic HMB. Improving adherence to this approach could improve quality of care and reduce costs.
| Original language | English |
|---|---|
| Pages (from-to) | 6-12 |
| Number of pages | 7 |
| Journal | European Journal of Obstetrics and Gynecology and Reproductive Biology |
| Volume | 283 |
| DOIs | |
| Publication status | Published - 2023 |
Bibliographical note
Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.Funding
We would like to thank Michiel ten Hove, Tijs van Gorp and Robin Stoof for their contribution to the data request to Vektis and Jordy Breet for the execution of the pilot study. Dr. Robert Sykes (Doctored Limited, www.doctored.org.uk) provided technical editing assistance for the final drafts of this manuscript. MV, FP, BM, and MB designed the study. MV, EH were involved in the compliance procedure to retrieve the data from Vektis. TW analyzed the data and XK provided feedback to the statistical analyses performed. MV and FP drafted the manuscript. All authors reviewed and approved the final manuscript. None declared.
