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Rethinking hysterectomy

A COLLABORATIVE group of local clinicians, greater clinical guidance, and an unexpected jolt from COVID-19, is helping to turn the tide on the high rates of hysterectomy in regional Victoria.

Australia’s relatively high rate of hysterectomy was thrust into the spotlight early in the nation’s investigations into healthcare variation.

The Australian Commission on Safety and Quality in Health Care’s CEO Professor Debora Picone notes that the initial Organisation for Economic Co-operation and Development study into healthcare variation in 2012 found that Australia’s hysterectomy rates were considerably higher than rates in most other comparable nations.

Then, in 2017, the Second Australian Atlas of Healthcare Variation provided an important clue to addressing this high rate. It showed that in Australia rates of hysterectomy for a non-cancer indication were markedly higher in inner and outer regional areas than in major cities or remote areas. Three areas in regional Victoria had the highest rates of hospitalisations for hysterectomy in the country.

The Maryborough-Pyrenees region (763 procedures per 100,000 women aged 15 years and over), Ballarat region (744/100,000) and Creswick-Daylesford-Ballan region (639/100,000) had hysterectomy rates almost seven times higher than the areas with the lowest rates, including Gungahlin in the ACT (115/100,000) and Melbourne City (119/100,000).

‘Clearly, in those settings, hysterectomy was being overused, instead of non-surgical alternatives for heavy menstrual bleeding,’ Professor Picone says.

Rebecca Doherty, Senior Project Manager in Quality and Safety Analytics at Safer Care Victoria, says it was surprising to find such a concentration of hysterectomies in regional Victoria.

‘There is always going to be some variation,’ she says, ‘but to find [this degree of variation] was a surprise. Our approach was to try and understand the factors contributing to the difference.’

Equitable access

Around 25% of Australian women report heavy menstrual bleeding, which is defined as ‘excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life’. At times this can be severe enough to need a GP visit and discussion of treatment options.

Speaking at the launch of the Second Atlas, women’s health journalist Mia Freedman emphasised the importance of equitable access to best practice care for the management of heavy menstrual bleeding.

‘It is important that women don’t feel pressured into accepting the most invasive option – hysterectomy – if effective but less invasive treatments may also be suitable for them.’

Ms Freedman noted that, for her, a hormonal intrauterine device (IUD) was the best option.

‘The whole process took maybe 30 minutes including finding a parking spot,’ she said. ‘Compare this to a hysterectomy – the cost to me, the healthcare system, my family and the economy.’

Clinical Care Standard

To encourage the adoption of evidence-based practice nationally, the Commission developed the Heavy Menstrual Bleeding Clinical Care Standard.

The standard promotes informed choice and shared-decision making in managing heavy menstrual bleeding when treatment is needed. After assessment and diagnosis to exclude serious causes, it recommends initial pharmaceutical treatment either orally or via an intra-uterine hormonal device. If these options are not successful or suitable, less invasive procedural options should be considered before hysterectomy. These include endometrial ablation, or if the bleeding is thought to be caused by fibroids, laparascopic removal or treatment using a radiological procedure called uterine artery embolization.

If sonography is required, the standard emphasises the importance of a high quality ultrasound (preferably transvaginal) at the right time in the woman’s cycle.

Ms Alice Bhasale, Director, Clinical Care Standards at the Commission, says the high use of hysterectomy in Australia perhaps reflects a mistaken belief in the community that women who’d had children no longer needed their uterus.

‘We wanted people to be aware of the different choices that they could be making,’ Ms Bhasale says.

‘One of the barriers to using the IUD was an initial lack of confidence among GPs, who require training to insert the device. Some GPs also thought [this service] wasn’t adequately recompensed.’

But, she says, the Standard has increased awareness of this option amongst patients, and GP training and confidence has improved.

Grassroots change

Building upon national efforts to shift heavy menstrual bleeding management practices, Safer Care Victoria promoted the new Clinical Care Standard in a one-day forum.

Also, a regional working group—comprising representatives from local hospitals and primary care settings as well as a consumer representative – was established to reflect on the reasons for the variation.

‘We found that heavy menstrual bleeding was one of several health issues leading to women undergoing hysterectomy, although we didn’t have information about what other treatment options they might have tried,’ Ms Doherty says.

Access to less invasive treatments, such as the hormonal IUD, did not seem to be a significant issue in these areas, she says.

Ms Doherty says it is difficult to tease out how much of this variation was driven by patient preference, as planned qualitative research was not able to proceed due to COVID and other factors.

‘One question raised by the working group was whether women living in the area knew of other women who had chosen hysterectomy as a treatment option, making this a more familiar way to manage heavy menstrual bleeding.’

In July 2019, off the back of the high rates of hysterectomy in its catchment, Maryborough District Health Service launched its Well Women’s Clinic after a co-design project with the local women in the community. The clinic supports local and timely access to primary care management of heavy menstrual bleeding, as well as other important screening and female-related health issues. Since July 2019 more than 250 women have accessed this service.

COVID-19 impact

The suspension of all non-urgent elective surgery in Victoria during last year’s COVID-19 lockdown also had an unexpected impact on the state’s hysterectomy rate.

As elective procedures were gradually reintroduced after the suspension, it was necessary to prioritise the most beneficial interventions.

Safer Care Victoria and the Victorian Department of Health used the opportunity to work closely with expert clinicians and consumers to review the evidence for a range of procedures and to provide guidance that could support patients and clinicians to discuss treatment options and make informed decisions together.

Hysterectomy, for a range of indications (including heavy menstrual bleeding), was one of the procedures included in the review.

While hysterectomy rates are not examined in the latest Atlas, it is hoped that better awareness of the management options will help women to make decisions that are right for them, Ms Doherty says.

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