良性疾病過度使用子宮切除術


  【24drs.com】根據線上發表於2014年12月23日婦產科期刊一篇子宮切除術前後資料的分析研究結果,子宮異常出血(AUB)與其他良性疾病,子宮切除術之外替代療法的使用率過低;有這些情況者進行子宮切除術之後,18.3%沒有病理證據支持。
  
  密西根州底特律韋恩州立大學醫學院的Lauren E. Corona等人表示,美國婦產科醫師協會支持使用子宮切除術的替代療法,包括荷爾蒙、宮腔鏡手術、子宮內膜燒灼術、使用levonorgestrel子宮內避孕器(IUD)做為許多案例在這些狀況的主要處置方式。雖然使用這些替代療法使子宮切除術的利用率降低,評估子宮切除術的適當性仍然是品質改善的目標。根據子宮切除術的適用準則,過度使用率估計為16-70%。
  
  研究者使用2013年1月1日至11月8日期間、密西根州手術品質合作的52所醫院的資料,分析使用替代療法以及進行子宮切除術治療良性疾病之婦女的病理資料,這些良性疾病包括:子宮肌瘤、異常子宮出血、子宮內膜異位症、骨盆腔疼痛,異常子宮出血是最常見的適應症。
  
  在這段研究期間內進行子宮切除術的6,042名婦女中,3,397人(56.2%)符合納入分析的準則,超過三分之一(1,281人;37.7%)在進行子宮切除術前沒有用過替代療法,621人(18.3%)的病理結果不支持,也就是說沒有肌瘤、子宮內膜異位症、子宮內膜增生、子宮腺肌症、附屬器官病變或意外的癌症等證據就進行子宮切除。
  
  根據多變項分析,與子宮切除術前接受替代治療有關的獨立因素,子宮體積比較大且小於40歲、40-50歲、50歲以上的比率分別是68% vs 62% vs 56%(P < .001)。
  
  與病理結果不支持有關的獨立因素,包括子宮體積比較小、子宮內膜異位症或疼痛之適應症,相較於子宮肌瘤和/或子宮異常出血,年紀比較輕,病理結果不支持的比率,小於40歲的婦女為37.8%、40-50歲婦女為12.0%、50歲以上婦女為7.5%(P < .001)。
  
  研究限制包括,僅依賴醫療紀錄、可能有取樣偏差、缺乏術前影像檢查結果的分析。
  
  研究作者結論表示,有18%的婦女沒有病理結果支持需要進行子宮切除術這個事實,大部分婦女在進行子宮切除術前會使用一種替代療法,表示還有機會降低子宮切除術的利用率。levonorgestrel子宮內避孕器是治療異常子宮出血和骨盆腔疼痛的最有效替代方法,應可大大地得到充分利用。避免子宮切除術的主要目標是改善品質和節省費用。
  
  資料來源:

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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