Rates and Routes of Hysterectomy for Benign Indications in Austria 2002 - 2014.

DOI https://doi.org/10.1055/s-0043-107784 Geburtsh Frauenheilk 2017; 77: 482 –486 © Georg Thieme Verlag KG Stuttgart · New York | ISSN 0016 ‑5751 Correspondence Karl Tamussino, MD Department of Obstetrics & Gynecology, Medical University of Graz Auenbruggerplatz 14, A-8036 Graz, Austria [email protected]

Introduction Rates and routes of hysterectomy have impli- cations for quality, costs and training. This study analyzed rates of benign hysterectomy and surgical approaches for be- nign hysterectomy in Austria from 2002 to 2014.

This was a population-based retro- spective observational study of coding data from all acute care hospitals (public and private) in Austria. Main outcome measures were numbers of women undergoing hysterectomy for benign indications in Austria per year and the route of hys- terectomy for benign indications.

The number of benign hysterectomies performed per year declined from 10 675 in 2002 to 7747 in 2014, a decline of 27 %. The use of vaginal hysterectomy was stable (53 % and 47 %, respectively). Use of laparoscopic techniques increased (5 % in 2002, 32 % in 2014) whereas use of abdominal hyster- ectomy decreased (41 % and 20 %, respectively).

Numbers of benign hysterectomies performed per year in Austria declined substantially between 2002 and 2014. Use of vaginal hysterectomy was stable at about 50 %, whereas increased use of laparoscopic techniques was associ- ated with lower rates of open hysterectomy. ZUSAMMENFASSUNG Einleitung Die Anzahl durchgeführter Hysterektomien und der gewählte operative Zugangsweg haben Implikationen für Qualität, Kosten und ärztliche Ausbildung. In dieser Studie wurden die Anzahl der in Österreich zwischen 2002 und 2014 durchgeführten benignen Hysterektomien und der gewählte operative Zugangsweg untersucht.

und Methoden Es handelt sich hier um eine retro- spektive bevölkerungsbezogene Beobachtungsstudie basie- rend auf codierten Daten aus allen (öffentlichen und privaten) Akutkrankenhäusern in Österreich. Die wichtigsten Ergebnis- se waren die jährliche Anzahl der Frauen in Österreich, die sich einer Hysterektomie für benigne Grunderkrankung unterzo- gen, sowie der gewählte operative Zugangsweg. Ergebnisse Die Anzahl der jährlich durchgeführten Hyster- ektomien für benigne Erkrankungen ging von 10 675 im Jahre 2002 zurück auf 7747 im Jahr e 2014, was ein em Rückgang von 27 % entspricht. Der Anteil vaginaler Hysterektomien blieb relativ stabil (53 % resp. 47 %). Laparoskopische Metho- den wurden zunehmend eingesetzt (5 % im Jahre 2002, 32 % im Jahre 2014), während der Anteil abdominaler Hysterekto- mien abgenommen hat (41 % resp. 20 %). Schlussfolgerungen Die Anzahl der jährlich in Österreich für benigne Grunderkrankungen durchgeführten Hysterekto- mien ist zwischen 2002 und 2014 erheblich zur ückgegangen. Der Anteil vaginaler Hysterektomien blieb stabil mit ca. 50 %, wohingegen der verstärkte Einsatz laparoskopischer Verfah- ren mit niedrigeren Raten von abdominalen Hysterektomien einherging. 482 Edler KM et al. Rates and Routes … Geburtsh Frauenheilk 2017; 77: 482 –486 GebFra Science | Original Article Key Message Rates of benign hysterectomy in Austria per year declined by 27 % between 2002 and 2014. Use of vaginal hysterectomy was stable at about 50 %; increased use of laparoscopic techniques was asso- ciated with lower rates of open hysterectomy.

Hysterectomy is a common surgical procedure in women and most hysterectomies are performed for benign indications [1]. Hysterec- tomy rates vary considerably among regions and countries [2 –12]. Medical and hormonal treatments (such as the levonorgestrel-re- leasing intrauterine device) and less invasive surgical options (such as endometrial ablations) have contributed to declining hysterec- tomy rates in numerous countries [2 –12]. The subject of benign hysterectomy has received and continues to receive considerable attention in the medical literature and in the lay press [13 –15]. In addition, hysterectomy can be done by various routes and with dif- ferent technologies, and these have shifted and evolved over the years [1, 10, 11]. It is now widely agreed that hysterectomies should be performed by a minimally invasive approach, i.e., vaginally or laparoscopically, if possible. Furthermore, rates and routes of hys- terectomy have implications for quality, costs and training. We used a national database to analyse both hysterectomy rates and surgical routes for hysterectomy for benign indications in acute care hospitals in Austria between 2002 and 2014.

Rates and routes of hysterectomy were analysed from data collated by the Austrian Ministry of Health and Women ʼs Affairs, data eval- uation was done by GÖG (Gesundheit Österreich GmbH). The GÖG is a government agency with the mission to research, plan and co- ordinate healthcare in Austria. The data for the study derive from the Austrian DRG system (Diagnosen- und Leistungsdokumenta- tion der österreichischen Krankenanstalten 2002 –2014, DLD), which is used by all hospitals and therefore covers all inpatient treatments in both public and private hospitals in Austria. The DLD is a documentation system initiated in 1997 and is based on the ICD-10 coding system for diagnoses and so-called MEL codes (Medizinische Einzelleistung) for medical procedures. In 2002, this coding system was expanded to include the route of hysterectomy. The Austrian system has seven separate codes for hysterectomies: laparoscopic supracervical hysterectomy, total and laparoscop- ically assisted hysterectomy, abdominal hysterectomy, vaginal hys- terectomy, radical laparoscopic hysterectomy, radical abdominal hysterectomy and radical vaginal hysterectomy. We identified all inpatient stays in Austria with the intervention “Hysterectomy ” from 2002 to 2014. MEL codes were linked to the coded diagnoses during the respective stay in order to ascertain which type of hysterectomy was done for which indication. Rates for hysterectomy for benign indications were calculated by sub- tracting hysterectomies performed for a malignant condition from the overall number of hysterectomies. Hysterectomies coded for transgender patients were not included in the calculated rates per 100 000 women, but are included in absolute numbers. Age-adjusted rates were calculated as the number of inpatient stays with the intervention “Hysterectomy ” per 100 000 women referring to the mean European standard population 2013 ob- tained from Eurostat. Because this was a secondary analysis of anonymized data, the protocol was not submitted to the institutional ethics committee.

Rates A total of 140 329 hysterectomies were performed in acute care hospitals in Austria between 2002 and 2014. The overall number of hysterectomies per year declined steadily from 12 764 in 2002 to 9501 in 2014. This is a decline of 25 % – with 3263 fewer hyster- ectomies performed in 2014 than in 2002. The age-adjusted over- all hysterectomy rate thus decreased from 316/100 000 women in 2002 to 206/100 000 women in 2014. Over the entire study period the large majority of hysterecto- mies were done for benign indications (84 % in 2002 and 82% in 2014; ▶ Fig. 1). While the number of hysterectomies done for a malignant indication decreased by 16 % ( 2089 in 2002 vs. 1754 in 2014), the number of hysterectomies performed for benign indi- cations decreased by 27 % (10 675 in 2002 vs. 7747 in 2014). The age-adjusted hysterectomy rate for benign indications decreased from 265/100 000 in 2002 to 168/100 000 women in 2014. Three indications accounted for 78 % of the benign indications for hysterectomy: leiomyomas (42 %), pelvic organ prolapse (25 %) and abnormal uterine bleeding (11 %). Other benign indications included endometriosis, adenomyosis, chronic pelvic pain, cervi- cal atypia, infections, benign tumors other than fibroids, and peri- partal complications. Routes Minimally invasive techniques, specifically vaginal hysterectomy, were the most frequently used techniques for benign indications. In 2014, 47 % of benign hysterectomies were done vaginally, 23 % laparoscopically, 20 % abdominally, and 9.3 % as laparoscopic 20000 10000 0 2002 2004 2006 2008 2010 2012 2014 Total number of hysterectomies Hysterectomies for benign indications ▶ Fig. 1 Numbers of hysterectomies (overall and for benign indica- tions) in Austria 2002 –2014. Source: MoHW – DLD 2002 –2014; data evaluation by GÖG. 483Edler KM et al. Rates and Routes … Geburtsh Frauenheilk 2017; 77: 482 –486 supracervical hysterectomies; in 2002 the respective numbers were 53 %, 3.1 %, 41 %, and 2.5 % ( ▶ Fig. 2). Thus, use of laparo- scopic hysterectomy increased at the expense of abdominal hys- terectomy, whereas the use of vaginal hysterectomy was near 5 0 %i nb o t ht i m ep e r i o d s( ▶ Fig. 2). Robotically-assisted hysterec- tomy is a rarity in Austria.

Within the relatively brief period of 13 years, hysterectomy rates for benign indications in Austria fell by 27 %. This amounts to a major change in gynecologic practice. Regarding the routes of be- nign hysterectomy, laparoscopic approaches reduced the rate of abdominal hysterectomy from 41 % to 20 %; the rate of vaginal hysterectomy was stable near 50 %. A number of factors are likely to have contributed to the de- cline of benign hysterectomy in Austria. Less invasive treatment options – such as endometrial ablations, levonorgestrel-releasing intrauterine devices (introduced in Austria in 1997), other hormo- nal interventions, uterine artery embolization (UAE) – have been used increasingly to treat benign conditions such as abnormal uterine bleeding and fibroids. Also, it is likely that today neither women nor providers consider hysterectomy a first-line treatment for benign gynecologic conditions. Declining hysterectomy rates in recent years have been re- ported from Australia [3], the Netherlands [9, 16], England [8, 21], Switzerland [4], Portugal [12], and Denmark [22]. In the USA, rate reductions of 36 –39 % in benign hysterectomies have been reported [10, 11]. Comparing hysterectomy rates amongst different countries is complicated by differences in data collection, definitions and doc- umentation as well as by different populations used for age-ad- justment. With an overall hysterectomy rate of 207/100 000 and a hysterectomy rate for benign indications of 168/100 000 wom- en in 2014, the hysterectomy rate in Austria is low compared to that reported from other countries ( ▶ Table 1 ). The large variations in hysterectomy rates amongst countries with similar demographics imply that nonmedical factors influ- ence the rates of hysterectomy. Specifics of local health care and reimbursement systems likely play a role, as do differences in atti- tude and clinical practice patterns [14 –18]. In Austria, vaginal hysterectomy remains the most common approach to benign hysterectomy, with rates near 50 % through 2002 and 2014. The advance of laparoscopic surgery has in- creased the proportion of minimally invasive hysterectomies at the expense of abdominal hysterectomy (in Austria robotic hyster- ectomy is practically non-existent). This is consistent with efforts to increase the rate of minimally invasive approaches for hysterec- tomy for benign conditions. There are remarkable variations in the use of different opera- tion routes for benign hysterectomy amongst countries. In West- ern Australia 45 % [3], in France 58 % [19], in Germany 55 % [7], in Finland 44% [20], and in the Netherlands 51 % [9], Portugal 21% [12], Denmark approximately 20 % [22] of benign hysterectomies are performed by the vaginal route. In contrast, laparotomy is the preferred approach in the U. S. (54% of inpatient hysterectomies [11]) and Sweden (63 %) [6]. Robotically-assisted hysterectomy, which accounted for 9.5 % of all hysterectomies in the United States in 2010 [23], is practically non-existent in Austria. Hysterectomy rates over time in the United States have been looked at by Wright et al. [11, 23] and more recently by Doll et al. [10]. Wright et al., analysing inpatient procedures, reported that the number of hysterectomies (including those done for cancer) Number of hysterectomies 7 6 5 4 3 2 1 0 000 000 000 000 000 000 000 2002 (JK120) Vaginal hysterectomy (JK110) Abdominal hysterectomy (JK100) Laparoscopic or laparoscopically assisted vaginal hysterectomy (JK090) Laparoscopic supracervical hysterectomy 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 ▶ Fig. 2 Routes of benign hyster ectomy in Austria 2002 –2014. Source: MoHW – DLD 2002 –2014; data evaluation by GÖG. 484 Edler KM et al. Rates and Routes … Geburtsh Frauenheilk 2017; 77: 482 –486 GebFra Science | Original Article performed annually decr eased by 36 % between 2002 and 2010 [11]. Abdominal hysterectomies accounted for 69 % of procedures in 2002, declining to 54 % by 2010; the use of vaginal hysterec- tomy declined from 25 to 17 % [11]. Use of laparoscopic hysterec- tomy declined from 15% in 2006 to 8.6 % in 2010, whereas use of robotic hysterectomy increased markedly, from 0.2 to 8.2 % [11, 23]. These figures did not include patients discharged on the day of surgery and thus probably underestimate the numbers of min- imally invasive hysterectomies. Looking only at benign hysterec- tomies, Wright et al. reported an increase of the use of robot- ically-assisted hysterectomy from 0.5% in 2007 to 9.5% in 2010 [23]. In hospitals where robotic hysterectomies were done, ro- botic procedures accounted for over 22 % of benign hysterecto- mies [23]. More recently, Doll et al. [10] reported that overall annual hysterectomy rates in commercially insured women de- creased by 39 % from 2000 to 2014, and that in 2014 70 % of be- nign hysterectomies were performed in an outpatient setting [10]. Doll et al. [10] did not report on routes of hysterectomy. The reports from the U. S. by Wright et al. [11, 24] and Doll et al. [10] predate the morcellation debate that began in 2013 and led to an FDA safety communication on laparoscopic power mor- cellation in April 2014. Today, worries regarding morcellation of uteri containing unrecognized malignancy may influence deci- sions about the route of hysterectomy for presumed benign dis- ease. In 2016 Harris et al. [24] looked at over 15 000 benign hys- terectomies in the Michigan Surgical Quality Collaborative before and after the FDA Communication in April 2014 and found a 4.1 % decrease in laparoscopic procedures and a commensurate in- crease in open and vaginal procedures. Similarly, a 5 % increase in the rate of open hysterectomies was reported from the Kaiser Per- manente system [25]. Reviews and guidelines consistently underline that vaginal hys- terectomy, if feasible, is the method of choice concerning out- come and costs [13, 26 –28]. The comparatively high and stable rate of vaginal hysterectomy in Austria is encouraging in this re- gard. The strengths of our study are the consistent acquisition of data over a 13-year time period in an entire (albeit small) country with a high-quality healthcare system and a strong tradition in gynecologic surgery and vaginal surgery in particular. Also, since all hysterectomies in Austria are performed on an inpatient basis (in contrast to the situation in the U. S. [10]), we captured virtually all procedures. Limitations are that coding may not always cor- rect, though we consider major coding problems regarding be- nign vs. malignant procedures or the route of the procedures un- likely. Also, we have no data on complications because these data are not recorded centrally. In conclusion, hysterectomy rates for benign indications in Austria declined by 27 % in the 13 years between 2002 and 2014. This is a major shift in clinical practice and has implications for costs and training. In the era of work-hour restrictions, the num- bers of hysterectomies required in training and certification pro- grams may not be realistic. Austria ranks among countries with low hysterectomy rates. The decline in benign hysterectomy rates is likely due to an increased use of conservative treatment options, both medical and surgical. The proportion of benign hysterecto- mies performed with a minimally invasive approach increased from 58 % to 79 %, with an increase in laparoscopic hysterectomies seen at the expense of abdominal hysterectomies. This is encour- aging and consistent with efforts to increase rates of minimally in- vasive approaches. Funding There was no external funding for this study. ▶ Table 1 Hysterectomy rates (and definitions) in different countries. Country Authors Benign/ malignant/total Year Hysterectomy rate Austria Current study 2016 Total 2014 206/100 000 women Austria Current study 2016 Benign 2014 167/100 000 women Germany Stang 2011 Total 2005 –2006 362/100 000 person years Germany Stang 2011 Benign 2005 –2006 295/100 000 person years Switzerland Schweizer Gesundheitsobservatorium 2007 Total 2005 2.9/1000 female residents USA Whiteman 2008 Total 2003 5.1/1000 women Western Australia Spilsbury 2006 Total 2003 4.8/1000 women years New Zealand Scott 1995 Total 199 1 365/100 000 women Sweden Lundholm 2009 Benign 2003 210/100 000 women years Denmark Gimbel 2001 Total 1998 182/100 000 women Netherlands Hanstede 2012 Benign 1995 –2005 17.2 per 10 000 women Portugal Gante et al. 2017 Total 2000 –2014 212 and 171/100 000 women per year 485Edler KM et al. Rates and Routes … Geburtsh Frauenheilk 2017; 77: 482 –486 Conflict of Interest None of the authors have competing interests relevant to this study.

[1] Falcone T, Walters MD. Hysterectomy for benign disease. Obstet Gyne- col 2008; 111: 753 –767 [2] Gimbel H, Settnes A, Tabor A. Hysterectomy on benign indication in Denmark 1988 –1998. A register based trend analysis. Acta Obstet Gyne- col Scand 2001; 80: 267 –272 [3] Spilsbury K, Semmens J, Hammond I et al. Persistent high rates of hyster- ectomy in Western Australia: a population-based study of 83000 proce- dures over 23 years. BJOG 2006; 113: 804 –809 [4] Schweizer Gesundheitsobservatorium. Hospitalisationsrate in somati- schen Akutspitälern wegen Gebärmutterentfernung (Hysterektomie) pro 1000 Einwohnerinnen und Kaiserschnitt pro 1000 Geburten. Obsan November 2007 (Indikator 6.4.13) [5] Whiteman MK, Hillis SD, Jamieson DJ et al. Inpatient hysterectomy sur- veillance in the United States, 2000 –2004. Am J Obstet Gynecol 2008; 198: 34.e1 –34.e7 [6] Lundholm C, Forsgren C, Johansson AL et al. Hysterectomy on benign in- dications in Sweden 1987 –2003: a nationwide trend analysis. Acta Ob- stet Gynecol Scand 2009; 88: 52 –58 [7] Stang A, Merrill RM, Kuss O. Hysterectomy in Germany: a DRG-based na- tionwide analysis, 2005 –2006. Dtsch Arztebl Int 2011; 108: 508 –514 [8] Cromwell D, Mahmood T, Templeton A et al. Surgery for menorrhagia within English regions: variation in rates of endometrial ablation and hys- terectomy. BJOG 2009; 116: 1373 –1379 [9] Hanstede MM, Burger MJ, Timmermans A et al. Regional and temporal variation in hysterectomy rates and surgical routes for benign disease in the Netherlands. Acta Obstet Gynecol Scand 2012; 91: 220 –225 [10] Doll KM, Dusetzina SB, Robinson W. Trends in inpatient and outpatient hysterectomy and oophorectomy rates among commercially insured women in the United States, 2000 –2014. JAMA Surg 2016; 151: 876 – 877 [11] Wright JD, Herzog TJ, Tsui J et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obs tet Gyne col 2013; 122: 233 –241 [12] Gante I, Medeiros-Borges C, Águas F. Hysterectomies in Portugal (2000 – 2014): what has changed? Eur J Obstet Gynecol Repod Biol 2017; 208: 97–102 [13] Aarts JWM, Nieboer TE, Johnson N et al. Surgical approach to hysterec- tomy for benign gynaecological disease. Cochrane Database Syst Rev 2015; (8): CD003677 [14] Domenighetti G, Casabianca A. Rate of hysterectomy is lower among fe- male doctors and lawyers ʼ wives. BMJ 1997; 314: 1417 [15] Domenighetti G, Luraschi P, Casabianca A et al. Effect of information campaign by the mass media on hysterectomy rates. Lancet 1988; 2: 1470–1473 [16] Brölmann HA, Vervest HA, Heineman MJ. Declining trend in major gy- naecological surgery in The Netherlands during 1991 –1998. Is there an impact on surgical skills and innovative ability? BJOG 2001; 108: 743 – 748 [17] Hall RE, Cohen MM. Variations in hysterectomy rates in Ontario: does the indication matter? CMAJ 1994; 151: 1713 –1719 [18] Jacobson GF, Shaber RE, Armstrong MA et al. Changes in rates of hyster- ectomy and uterus-conserving procedures for treatment of uterine leio- myoma. Am J Obstet Gynecol 2007; 196: 601.e1 –601.e5 [19] David-Montefiore E, Rouzier R, Chapron C et al. Surgical routes and com- plications of hysterectomy for benign disorders: a prospective observa- tional study in French university hospitals. Hum Reprod 2007; 22: 260 – 265 [20] Brummer TH, Jalkanen J, Fraser J et al. FINHYST, a prospective study of 5279 hysterectomies: complications and their risk factors. Hum Reprod 2011; 26: 1741 –1751 [21] Reid PC, Mukri F. Trends in number of hysterectomies performed in En- gland for menorrhagia: examination of health episode statistics, 1989 to 2002–3. BMJ 2005; 330: 938 –939 [22] Topsoee MF, Ibfelt EH, Settnes A. The Danish hysterectomy and hyster- oscopy database. Clin Epidemiol 2016; 8: 515 –520 [23] Wright JD, Ananth CV, Lewin SN et al. Robotically assisted vs. laparo- scopic hysterectomy among women with benign gynecologic disease. JAMA 2013; 309: 689 –698 [24] Harris JA, Swenson CW, Uppal S et al. Practice patterns and postopera- tive complications before and after US Food and Drug Administration safety communication on power morcellation. Am J Obstet Gynecol 2016; 214: 98.e1 –98.e13 [25] Saadat S, Arden D. How has the U.S. Food and Drug Administration mor- cellation warning affected rates of minimally invasive hysterectomy in a large multi-center managed care setting? [Abstract]. Am J Obstet Gyne- col 2017; 216 (Suppl.): S572 [26] ACOG Committee Opinion No. 444: Choosing the route of hysterectomy for benign disease. Obstet Gynecol 2009; 114: 1156 –1158 [27] Neis KJ, Zubke W, Römer T et al. Indications and route of hysterectomy for benign diseases – Guidelines of the DGGG, OEGGG and SGGG. Ge- burtsh Frauenheilk 2016; 76: 350 –364 [28] Deffieux X, Rochambeau Bd, Chene G et al. Hysterectomy for benign dis- ease: clinical practice guidelines from the French College of Obstetrics and Gynecology. Eur J Obstet Gynecol Reprod Biol 2016; 202: 83 –91 486 Edler KM et al. Rates and Routes … Geburtsh Frauenheilk 2017; 77: 482 –486 GebFra Science | Original Article