良性疾病过度使用子宫切除术


  【24drs.com】根据在线发表于2014年12月23日妇产科期刊一篇子宫切除术前后资料的分析研究结果,子宫异常出血(AUB)与其它良性疾病,子宫切除术之外替代疗法的使用率过低;有这些情况者进行子宫切除术之后,18.3%没有病理证据支持。
  
  密西根州底特律韦恩州立大学医学院的Lauren E. Corona等人表示,美国妇产科医师协会支持使用子宫切除术的替代疗法,包括荷尔蒙、宫腔镜手术、子宫内膜烧灼术、使用levonorgestrel子宫内避孕器(IUD)做为许多案例在这些状况的主要处置方式。虽然使用这些替代疗法使子宫切除术的利用率降低,评估子宫切除术的适当性仍然是质量改善的目标。根据子宫切除术的适用准则,过度使用率估计为16-70%。
  
  研究者使用2013年1月1日至11月8日期间、密西根州手术质量合作的52所医院的资料,分析使用替代疗法以及进行子宫切除术治疗良性疾病之妇女的病理资料,这些良性疾病包括:子宫肌瘤、异常子宫出血、子宫内膜异位症、骨盆腔疼痛,异常子宫出血是最常见的适应症。
  
  在这段研究期间内进行子宫切除术的6,042名妇女中,3,397人(56.2%)符合纳入分析的准则,超过三分之一(1,281人;37.7%)在进行子宫切除术前没有用过替代疗法,621人(18.3%)的病理结果不支持,也就是说没有肌瘤、子宫内膜异位症、子宫内膜增生、子宫腺肌症、附属器官病变或意外的癌症等证据就进行子宫切除。
  
  根据多变项分析,与子宫切除术前接受替代治疗有关的独立因素,子宫体积比较大且小于40岁、40-50岁、50岁以上的比率分别是68% vs 62% vs 56%(P < .001)。
  
  与病理结果不支持有关的独立因素,包括子宫体积比较小、子宫内膜异位症或疼痛之适应症,相较于子宫肌瘤和/或子宫异常出血,年纪比较轻,病理结果不支持的比率,小于40岁的妇女为37.8%、40-50岁妇女为12.0%、50岁以上妇女为7.5%(P < .001)。
  
  研究限制包括,仅依赖医疗纪录、可能有取样偏差、缺乏术前影像检查结果的分析。
  
  研究作者结论表示,有18%的妇女没有病理结果支持需要进行子宫切除术这个事实,大部分妇女在进行子宫切除术前会使用一种替代疗法,表示还有机会降低子宫切除术的利用率。levonorgestrel子宫内避孕器是治疗异常子宫出血和骨盆腔疼痛的最有效替代方法,应可大大地得到充分利用。避免子宫切除术的主要目标是改善质量和节省费用。
  
  资料来源:

Hysterectomy Overused for Benign Conditions

By Laurie Barclay, MD
Medscape Medical News

Alternatives to hysterectomy are underused in women with abnormal uterine bleeding (AUB) and other benign conditions, according to an analysis of perioperative hysterectomy data published online December 23, 2014, in the Journal of Obstetrics and Gynecology. When women with these conditions undergo hysterectomy, 18.3% have unsupportive pathology.

"The American Congress of Obstetricians and Gynecologists...supports the use of alternatives to hysterectomy including hormonal management, operative hysteroscopy, endometrial ablation, and use of the levonorgestrel intrauterine device (IUD) as primary management of these conditions in many cases," write Lauren E. Corona, BS, from Wayne State University School of Medicine, Detroit, Michigan, and colleagues. "Although use of these alternative treatments has recently led to a decrease in the utilization of hysterectomy, assessing the appropriateness of hysterectomy continues to be a target for quality improvement. Applying appropriateness criteria to hysterectomy, overutilization has been estimated to range from 16-70%."

Using data from 52 hospitals in the Michigan Surgical Quality Collaborative from January 1 through November 8, 2013, the researchers analyzed use of alternative treatments and pathology among women who underwent hysterectomy for benign indications, including uterine fibroids, AUB, endometriosis, or pelvic pain. AUB was the most common indication.

Of 6042 women who had hysterectomy during the study period, 3397 (56.2%) met inclusion criteria for analysis. More than one third of these (1281; 37.7%) had no documentation of alternative treatment before hysterectomy, and 621 (18.3%) had "unsupportive" pathology, meaning that hysterectomy showed no evidence of fibroids, endometriosis, endometrial hyperplasia, adenomyosis, adnexal pathology, or unexpected cancer.

Factors independently associated with receiving alternative treatment before hysterectomy, based on multivariable analysis, were larger uterine size and age younger than 40 years compared with ages 40 to 50 years and older than 50 years (68% vs 62% vs 56%; P < .001).

Factors independently associated with unsupportive pathology were smaller uterine size, indication of endometriosis or pain vs uterine fibroids and/or AUB, and younger age. Rates of unsupportive pathology were 37.8% in women younger than 40 years of age, 12.0% in those aged 40 to 50 years, and 7.5% in those older than 50 years (P < .001).

Limitations of this study include reliance on medical records, potential for selection bias, and lack of access to preoperative imaging.

"The fact that 18% of women did not have pathology supportive of the need for hysterectomy and that the majority of women consider at most 1 alternative treatment prior to hysterectomy indicates that there are opportunities to decrease the utilization of hysterectomy," the study authors conclude. "The levonorgestrel IUD, which is one of the most effective alternative treatments for AUB and pelvic pain, may be vastly underutilized. These are prime targets for quality improvement and cost savings by avoiding hysterectomy."

The Pelvic Floor Research Group receives research support from American Medical Systems, Johnson & Johnson, Kimberly Clark, and Proctor & Gamble through the University of Michigan. The authors have disclosed no relevant financial relationships.

J Obstet Gynecol. Published online December 23, 2014.

    
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