Nearly 1 in 5 women who undergo hysterectomy may not need the procedure
JANUARY 06, 2015
Media Contact: Beata Mostafavi 734-764-2220

Study: Hysterectomies are declining overall but alternatives to hysterectomy are still being underutilized.

ANN ARBOR, Mich. —  A University of Michigan-led study of nearly 3,400 women in Michigan shows that one in five who underwent a hysterectomy for benign conditions may not have needed it.

The findings, which appear in the American Journal of Obstetrics and Gynecology, indicate that alternatives to hysterectomy are being underused and that treatment guidelines are often not followed.

An estimated one in three women in the U.S. will have had a hysterectomy by the age of 60.  Researchers found that although the numbers of hysterectomies are decreasing, nearly 18 percent of hysterectomies that were done for benign indications were unnecessary, and a pathology analysis for nearly two in five (38 %) of women under 40 did not support undergoing a hysterectomy.

“Over the past decade, there has been a substantial decline in the number of hysterectomies performed annually in the United States,” says senior author Daniel M. Morgan, M.D., associate professor in the Department of Obstetrics and Gynecology at the U-M Medical School.

“An earlier study found a 36.4% decrease in number of hysterectomies performed in the U.S. in 2010 compared to 2002. However, despite the decrease in numbers of hysterectomies in the U.S., appropriateness of hysterectomy is still an area of concern and it continues to be a target for quality improvement.”

More than 400,000 hysterectomies are performed in the U.S. each year. About 68% of surgeries for benign conditions are done because of abnormal uterine bleeding, uterine leiomyomata (fibroids), and endometriosis. The American Congress of Obstetricians and Gynecologists recommends alternatives to hysterectomy, including hormonal management, a minimally invasive gynecological procedure called operative hysteroscopy, endometrial ablation (a procedure that destroys the uterine lining) and use of an intrauterine device as primary management of these conditions in many cases.

Researchers set out to assess how often alternatives to hysterectomy are being recommended to women with benign gynecologic disease before performing hysterectomy and how often the pathologic findings from the hysterectomy supported an indication for surgery. They examined the medical records of 3,397 women who underwent hysterectomies for benign conditions in Michigan. Data were collected over a ten-month period in 2013 from 51 hospitals participating in the Michigan Surgery Quality Collaborative (MSQC). Indications for surgery included uterine fibroids, abnormal uterine bleeding, endometriosis, or pelvic pain.

Nearly 40% of women did not have documentation of alternative treatment before their hysterectomy. Fewer than 30% received medical therapy, while 24% underwent other minor surgical procedures before the hysterectomy. Alternative treatment was more likely to be considered among women under 40 years old and among women with larger uteri. About 68% of women under 40 received alternative treatment compared with 62% of those aged 40-50 and 56% of those aged 50 or above.

Nearly two in five women under 40 (38%) had pathologic findings that did not support undergoing a hysterectomy versus those aged 40-50 (12%) and over 50 years (7.5%). The frequency of unsupportive pathology was highest among women with endometriosis or chronic pain.

“This study provides evidence that alternatives to hysterectomy are underutilized in women undergoing hysterectomy for abnormal uterine bleeding, uterine fibroids, endometriosis, or pelvic pain,” Morgan says.

Additional Authors: Lauren Elizabeth Corona, of Wayne State University; and Carolyn W Swenson, M.D.; Kyle H Sheetz; Gwendolyn Shelby, R.N.; Mitchell B. Berger, M.D.; Mark D. Pearlman, M.D.; John O DeLancey, M.D., all of U-M. Darrell A. Campbell, Jr., U-M’s former chief medical officer. Pearlman and Morgan are also members of the U-M Institute for Healthcare Policy and Innovation. 

Funding: The MSQC is funded by the Blue Cross and Blue Shield of Michigan/ Blue Care Network.

Reference: “Use of Other Treatments before Hysterectomy for Benign Conditions in a Statewide Hospital Collaborative,” American Journal of Obstetrics & Gynecology, January, 2015.

Canadian endo sister forced to wait for laparoscopy – told she will “not suffer death or irreversible tissue damage”, so she should stop “doctor shopping, since this was a waste of both health-care resources and her time.” She was of course in agonising pain. Turns out once she came to the States to get surgery at Northside Hospital Cancer Institute, the surgeon had to remove her uterus, fallopian tubes, ovaries and nearly 8 inches of her bowel because of extensive endometriosis damage.

OHIP turns blind eye to suffering
COVERAGE: Area woman was chastised for seeking faster care before agency threw up roadblocks to paying for her care
By JONATHAN SHER, THE LONDON FREE PRESS
Last Updated: January 20, 2012 9:55pm

Chastened by doctors for seeking speedier treatment for a painful disease threatening to rob her of fertility, Allison Jones writhed with pain so severe it was like a man continually passing large kidney stones.

Jones needed to see one of a handful of gynecological specialists who could remove the lining of a uterus where it grows outside that organ, a painful condition called endometriosis.

But after waiting seven months to see a specialist Jones, a resident of Southwestern Ontario, was told she’d have to wait at least seven more for surgery that might make her pain-free for the first time in years.

Only one specialist held an open door to her care, a Canadian schooled almost entirely in Ontario. But Dr. Ken Sinervo had committed a Cardinal sin as far as OHIP was concerned — he offered life-changing surgery outside the country in Atlanta, Georgia.

Twice, Jones’ family doctor wrote to OHIP, asking the agency to pay for Siverno’s surgery, but each request was met by quick refusals and a suggestion she check a list of specialists, none of whom had time to see her any quicker.

One specialist, Dr. Sabrina Lee, chastised Jones for seeking faster access, writing in a letter she should stop “doctor shopping, since this was a waste of both health-care resources and her time.”

Jones sought emergency care repeatedly, but the heavy-duty drugs prescribed did little to curb her pain.

So in April of 2010, she decided to go to Atlanta.

Three days later, she was on an operating table at the Northside Hospital Cancer Institute.

“That’s one of the big differences between the health-care system in Canada and the system here,” Sinervo told The Free Press this week from Atlanta.

The disease had progressed so quickly, Sinervo had to remove her uterus, fallopian tubes, ovaries and nearly 8 inches of her bowel.

The ordeal was traumatizing. Jones — not her real name — asked The Free Press last week to keep her identity secret.

But those who helped her spoke out.

It isn’t just the speed of access that’s different, Sinervo says. The surgeries he performs in Atlanta are more advanced than what’s available in Ontario, in part because he performs surgery four or five days a week — while Ontario docs might get a day and a half because of the rationing of operating-room time.

“That’s one of the reasons I didn’t go back to Canada after my fellowship in Atlanta,” he said.

Sinervo uses a carbon-dioxide laser to remove all of the abnormal tissue to lessen the chance of complication and reoccurrences, something he says most specialists do not do.

The surgery was done, but the struggle for Jones had just begun: She faced a $70,000 medical bill including close to a week in hospital.

The Atlanta hospital, Northside Hospital Cancer Institute, later forgave most of the bill, wiping $57,000 off the books as it sometimes does for patients who just can’t afford to pay.

But OHIP fought against covering the remaining $13,000, even though that amount is almost certainly no more than what Jones’ treatment would have cost in Ontario, Sinervo said.

That hard-nosed approach is nothing new for OHIP, says the lawyer who represented Jones. For 20 years, the agency has acted strictly like a private insurance company, going to great lengths to avoid having to pay for any out-of-country care.

“There’s no compassion at all,” said Perry Brodkin, who was the agency’s in-house counsel years ago, before regulatory change changed it from an agency that tries to help to one seeking any reason to reject coverage.

Most patients lose appeals to OHIP rejections because they can’t afford to hire a lawyer, as legal costs typically range between $5,000 and $20,000.

Patients argue on compassionate grounds not to be found in a law that restricts out-of-country coverage to necessary care that’s unavailable here or so delayed a wait would probably result in death or medically significant and irreversible tissue damage.

Pain alone isn’t enough to get OHIP funding, no matter how excruciating or debilitating, Brodkin said.

But this time the bad guys lost, Brodkin said.

Jones won her appeal this month before Ontario’s Health Services Appeal and Review Board.

Board members took issue not just with the stance of OHIP, but also with the Ontario specialists who had essentially told Jones to wait her turn.

The specialist she was to have waited for was Dr. Nicholas Leyland, top dog at Health Sciences Centre at Hamilton’s McMaster University.

But when Jones went to Sinervo, Leyland wrote to support OHIP’s denial of coverage.

“We could have carried out the same kind of care that was provided by Dr. Sinervo, who was a trainee of ours a few years ago. This patient would not have suffered death or irreversible tissue damage in waiting for this surgery. Many patients are waiting for this procedure much longer,” Leyland wrote.

The board rejected Leyland’s claim, noting in his letter, he didn’t mention Jones’ specific condition or if delay would cause irreversible tissue damage, dismissing her claim because some other women with the same general condition had to wait longer.

“It is unfortunate that Dr. Leyland did not testify at the hearing,” the board wrote.

The board also took aim at OHIP: “The Appeal Board is troubled by (OHIP’s) assertion that since endometriosis is by definition a progressive disease, any further progression in the form of tissue damage is expected and is not medically significant.”

The decision is timely, Brodkin said, as waits for surgery by Leyland have grown to nine months, with about 60 women affected.

“Most wait and suffer damage,” he said. “(This case) may open the doors (for care in Atlanta),” Brodkin said.

The Toronto lawyer challenged Ontario Health Minister Deb Matthews to change the rules and process to give patients a fighting chance, even if it’s to arrange for an advocate or ombudsperson for those who can’t afford a lawyer.

As for Sinervo, he’d like to negotiate a reduced rate with the health ministry for Ontario women going to Atlanta’s Center for Endometriosis Care, something close to half of the regular charges.

The Free Press requested interviews three days this week with Matthews, a London MPP, but she didn’t make herself available.

Messages left for Leyland and Lam also weren’t returned.

State to review limited coverage, caps in student health plans
Regulations will be overhauled
By Kay Lazar
Globe Staff / December 21, 2008

State regulations that require college students to have health insurance but allow insurers to substantially limit coverage – potentially exposing seriously ill students and their families to enormous medical bills – will be overhauled, according to a top state official.

The Division of Health Care Finance and Policy is conducting a “soup to nuts” review because of mounting concerns that the limited coverage allowed by the 20-year-old rules has not kept pace with rising healthcare costs and has been inconsistent with the state’s recent overhaul of the health insurance system, said Commissioner Sarah Iselin.

Most of those 77,800 covered by the student health program have plans that cap payments at $50,000 a year per injury or illness. That limit can be easily exceeded by cancer treatments or one hospitalization after a serious accident. Iselin said her agency, which regulates student health plans, is considering whether to mandate more generous benefits.

Another 225,000 college students have declined the student health insurance program, meaning they are choosing instead to be covered by their parents’ plan or some other private plan. A 1988 state law mandates that all part- and full-time students have health coverage.

The problem of limited student health insurance is hardly unique to Massachusetts. New York’s attorney general launched a probe last month into such insurance plans, reportedly focused on the adequacy of the disclosure of policy terms and costs to students. More than half of the student health plans studied nationwide capped the maximum benefits paid for an injury or illness at $30,000, according to an investigation earlier this year by the Government Accountability Office, an arm of Congress.

In Massachusetts, the contrast between student policies and other healthcare policies is stark; the capped coverage allowed for students fails to meet the minimum standards set for other plans as part of the state’s 2006 near-universal health law.

“To say it’s OK for you to receive substandard care because you made a choice to be a student, that is offensive,” said Heather Knauer, a 23-year-old Tufts University senior.

“I am stuck,” she said, “between a rock and a hard place.”

Insurers say the college policies, with premiums that typically cost students $2,000 or less a year, are as comprehensive as possible given the need to keep the price tag affordable. It is, they say, a balancing act.

School administrators, meanwhile, say they, too, face a tough choice in juggling costs versus quality when negotiating these plans with insurance companies. “It’s really a challenge to find benefit levels that are affordable,” said Michelle Bowdler, senior director of health and wellness services at Tufts. She said the university’s plan raised its overall coverage cap from $50,000 to $100,000 about three years ago because Tufts officials thought $50,000 wasn’t enough.

Word of the state’s planned overhaul comes as college students lobby for better health coverage. Knauer is one of several students who recently met with Iselin’s division and asked, among other things, for data about how many students have faced medical bills beyond what their policies covered – something officials were unable to provide, Iselin acknowledged.

Iselin said her division would probably start requiring schools to track that number and to submit health plans for review before the start of each school year; now the policies arrive in November, three months after they begin.

Students are also faulting the state for allowing insurers to impose limits in other areas. Many cap prescription drug benefits at $1,500 yearly and limit outpatient services.

As part of taking a “really hard look” at the student health plans, Iselin hired an actuarial company this fall to study the financial impact on students if regulators required insurers to provide more generous benefits. The data are due in February.

“The challenge is to strike a balance, to ensure the adequacy of these benefits . . . with the affordability,” she said. “We may find that increasing [benefits] may not, in fact, turn out to be hugely expensive.”

That is what the students hope to see. “These plans are downright pathetic,” said Aaron Marden, a Tufts senior who founded the Student Health Organizing Coalition this fall. The Tufts coalition is planning to form chapters on other campuses.

Marden said he and other coalition leaders who met last month with Iselin’s office were not told about the state’s plan to overhaul regulations, nor asked to join an 11-member advisory group appointed by Iselin.

Marden said his coalition presented regulators with a list of questions and requests for data including whether insurers are applying a reasonable percentage of profits toward students’ medical services. A recent Business Week investigation of student health plans nationwide found the plans to be unusually lucrative for insurers.

Iselin acknowledged that her division lacks that information and said it would probably require schools or the insurers to start reporting it as early as July.

“I would like to see, at the very least, large, large warnings, for colleges to have to say that before you sign up for this plan, this may not be appropriate,” said Mark Wiranowski, 37, of Jamaica Plain, who was covered under his wife’s Simmons College plan, capped at $50,000, when a boulder crushed his leg while he was hiking last year in the Rockies. His medical bills were nearly $400,000. Through state and other financial aid, Wiranowski said he eventually got all but $10,000 covered.

“I was unprepared for how enormous medical bills can be and how woefully inadequate the student health plan was, and I was too busy to do the research,” he said. “I am fortunate I was not bankrupt.”