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Probability of Hysterectomy After Endometrial Ablation

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Probability of Hysterectomy After Endometrial Ablation Probability of Hysterectomy After Endometrial Ablation Mindyn K. Longinotti, MD, Gavin F. Jacobson, MD, Yun-Yi Hung, PhD, and Lee A. Learman, MD, PhD OBJECTIVE: To investigate risk factors for hysterectomy patient location for hydrothermal endometrial ablation after endometrial ablation. increased hysterectomy risk (P<.001). METHODS: This was a retrospective cohort analysis of CONCLUSION: Age is more important than type of data from Kaiser Permanente Northern California mem- procedure or presence of leiomyomas in predicting sub- bers, aged 25–60 years undergoing endometrial ablation sequent hysterectomy after endometrial ablation. from 1999 to 2004 and collected through 2007. Risk Women undergoing endometrial ablation at younger factors assessed included age, presence of leiomyomas, than 40 years of age are at elevated risk of hysterectomy, setting of procedure (inpatient or outpatient), and type of and rather than plateauing within several years of endo- endometrial ablation procedure (first generation, radio metrial ablation, hysterectomy risk continues to increase frequency, hydrothermal, or thermal balloon). Univari- through 8 years of follow-up. able and survival analyses were performed to identify risk (Obstet Gynecol 2008;112:1214–20) factors and estimate probability of hysterectomy. LEVEL OF EVIDENCE: II RESULTS: From 1999 to 2004, 3,681 women underwent endometrial ablation at 30 Kaiser Permanente Northern California facilities. Hysterectomy was subsequently per- enorrhagia is a major health problem confront- formed in 774 women (21%), whereas 143 women (3.9%) Ming premenopausal women and is the most had uterine-conserving procedures. Age was a significant common reason for gynecologic visits in the United predictor of hysterectomy (P<.001). Cox regression anal- States.1 Historically, when medical therapy for men- ysis found that compared with women aged older than 45 orrhagia failed, hysterectomy was the primary surgi- years, women aged 45 years or younger were 2.1 times cal option. Destruction of the endometrium by endo- more likely to have hysterectomy (95% confidence inter- metrial ablation has emerged as a minimally invasive val 1.8–2.4). Hysterectomy risk increased with each de- alternative to hysterectomy. Several randomized con- creasing stratum of age and exceeded 40% in women trolled studies have found that first-generation endo- aged 40 years or younger. Overall, type of endometrial metrial ablation techniques offer promising short- ablation procedure, setting of endometrial ablation pro- term results and are reasonable alternatives to cedure, and presence of leiomyomas were not predictors hysterectomy for menorrhagia.2–4 First-generation of hysterectomy. In analysis of individual procedure transcervical hysteroscopic methods include resection types, concomitant myomectomy was associated with a decreased risk of hysterectomy for patients receiving and ablation procedures (laser, loop resection, roller- -and out- ball cautery). Newer nonhysteroscopic techniques in ,(002.؍first-generation endometrial ablation (P volving heated fluid, thermal balloon, radio fre- quency, microwave energy, or cryotherapy have been From the Department of Obstetrics and Gynecology and Division of Research, Kaiser Permanente Northern California, San Francisco, California; and De- developed as technically easier alternatives than hys- partment of Obstetrics and Gynecology, Indiana University School of Medicine, teroscopy-based methods. A recent Cochrane review Bloomington, Indiana. concluded that success rates and complication profiles of Supported by Kaiser Permanente Northern California. newer techniques compared favorably with first-gener- Corresponding author: Mindyn K. Longinotti, MD, GME office, Kaiser San ation methods, although they included limited data on Francisco, 2425 Geary Boulevard, San Francisco, CA 94115; e-mail: hysterectomy rates beyond 2 years.5 Without long-term [email protected]. follow-up it is difficult to accurately counsel patients on Financial Disclosure The authors have no potential conflicts of interest to disclose. whether endometrial ablation techniques are more likely to replace, or merely delay, hysterectomy. © 2008 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. Few studies provide long-term comparative data. ISSN: 0029-7844/08 Published reports focus primarily on first-generation 1214 VOL. 112, NO. 6, DECEMBER 2008 OBSTETRICS & GYNECOLOGY methods and describe a wide range of hysterectomy that replaced the Admissions, Discharge and Transfer rates ranging from 8–29% beyond 5 years.6–13 Most and Outpatient Summary Clinical Record systems. A follow-up data come from practices and centers fo- separate database is maintained for descriptive pa- cused on minimally invasive surgery and may not thology reports. reflect the actual effectiveness of endometrial ablation All endometrial ablations performed from Jan- procedures in a more representative sample of prac- uary 1999 to December 2004 were identified. Study ticing gynecologists. To improve our knowledge of eligibility was limited to women aged 25.0 to 60.0 how best to counsel patients considering endometrial years at the time of endometrial ablation. Inpatient ablation, we conducted a large retrospective cohort endometrial ablations were identified from the analysis in a large managed care organization. Our goal Admissions, Discharge and Transfer database using was to estimate the relative importance of age, type ICD-9 code 68.23 listed as the primary procedure. endometrial ablation, procedure setting, and presence of Outpatient endometrial ablation was identified from leiomyomas in predicting endometrial ablation failure the Outpatient Summary Clinical Record database as defined by subsequent hysterectomy. using appropriate Physicians’ Current Procedural Terminology Coding System codes. For inpatient MATERIALS AND METHODS endometrial ablation, leiomyoma was diagnosed if Study data were collected from the Kaiser Permanente the discharge diagnosis included an appropriate Northern California program. Kaiser Permanente ICD-9 code (218.x) in any position for leiomyoma in Northern California is a prepaid group-model managed the Admissions, Discharge and Transfer database. For care organization that provides comprehensive medical outpatient endometrial ablation, leiomyoma was di- services to approximately 30% of the Northern Califor- agnosed if similar codes for leiomyoma were found in nia population and is demographically representative of any position in Outpatient Summary Clinical Record that population.14 Recent Kaiser Member survey data database at the time of endometrial ablation. note that for female members older than age 20 years, During the study period there were no Kaiser 62% are Caucasian, 7% are African American, 12% are Permanente Northern California policies or guide- Hispanic, 16% are Asian; 4% have less than 12 years lines regarding management of menorrhagia, preop- education, 15% are high school graduates, 41% have erative evaluation for endometrial ablation, or favor- some college, 40% are college graduates, 42% have ing a particular type of endometrial ablation. Each annual household income less than $50,000, and 71% facility independently decided whether they would are married or living as part of a couple. Kaiser Perma- offer or encourage development of local expertise for nente Northern California members are cared for exclu- any particular type of endometrial ablation. These sively by physicians and allied health professionals in decisions were local and depended on budgetary and The Permanente Medical Group, a multispecialty med- discretionary decisions of local leadership. We sur- ical partnership of more than 5,500 physicians, includ- veyed departmental leadership at all Kaiser Perma- ing approximately 500 gynecologists. nente Northern California facilities that performed The study used data from three comprehensive endometrial ablation to determine which technique(s) computerized clinical databases maintained by Kaiser were available during the study period for the inpa- Permanente Northern California. The Admissions, tient and outpatient settings. In Kaiser Permanente Discharge and Transfer hospitalization database con- Northern California, the first thermal balloon endo- tains records of discharge diagnoses and procedures metrial ablation procedures started in 1999, hydro- coded using International Classification of Diseases, thermal endometrial ablation started in 2001, and 9th Revision (ICD-9) codes. This database captures radio-frequency endometrial ablation started in 2002. procedures performed in Kaiser Permanente North- Resection and ablation first-generation endome- ern California ambulatory surgical centers. Outpa- trial ablation procedures were grouped together in the tient visits are coded in the Outpatient Summary database. Laser endometrial ablation was not per- Clinical Record database, which includes provider- formed at any facility. Nonhysteroscopic second- coded reasons for visits as well as the Physicians’ generation endometrial ablation procedures included Current Procedural Terminology Coding System thermal balloon endometrial ablation (Thermachoice, codes for outpatient procedures. Late in 2004, Kaiser Ethicon Inc., Menlo Park, CA), hydrothermal endo- Permanente Northern California implemented the metrial ablation (HydroThermAblator, Boston Scien- Kaiser Permanente HealthConnect system. Kaiser tific, Natick, MA); and radio-frequency endometrial
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