Hysterectomy is one of the most frequently performed surgical procedures in the United States but rates are highly variable by hospital and region. Hysterectomy rates were one of the very first procedures to be mapped by where people live and receive care in 1973, showing that type of care is very different depending on location. The Washington Health Alliance 2015 report Different Regions, Different Health Care: Where you Live Matters shows that this variation by location is true in today’s Washington State. The procedure also has a risk of complications (e.g., bladder injury, wound infection, nerve damage) and use of medical management or alternatives to hysterectomy that spare the uterus have been shown to be used less often than they should. This variation and potential harm to patients caused us to select this topic as a priority for 2017. We convened a workgroup of dedicated experts that met monthly from March 2017 to January of this year to look at evidence-based indications for hysterectomy as well as best practices for the surgery itself.

Our recommendations were recently adopted by Bree Collaborative members at the January meeting and we look forward to working on implementing these into clinical practice. Our workgroup’s goal is to promote appropriate use of hysterectomy, including pre-surgical counseling and evaluation, while recognizing individual variation based on clinical opinion and patient preference. We developed the recommendations to encourage clinicians to review guidelines with patients prior to hysterectomy to reduce unnecessary or inappropriate hysterectomies. Our recommendations apply to uterine leiomyoma (fibroids), abnormal menstrual bleeding, endometriosis, uterine prolapse, adenomyosis, or pain and exclude pregnancy, cancer and cancer prevention, emergency situations (e.g., due to trauma, childbirth), gender reassignment surgery, or incidental hysterectomy with indicated oophorectomy.

The workgroup reviewed clinical practice guidelines, available evidence, and relied on clinical expertise where evidence was lacking to develop three focus areas:

  • – Assessment and medical management, by indication
  • – Uterine sparing procedures, by indication
  • – Surgical procedure including follow-up care, emphasizing the enhanced recovery after surgery protocol and use of a minimally invasive approach

 

We include recommendations specific to patients including resources to think through your options as well as recommendations for providers, health plans, employers, and the Health Care Authority. Questions about this work? We would love to hear from you!

Ginny Weir, MPH
Program Director, Bree Collaborative