Compliance with the published RCOG guidelines in women undergoing hysterectomy for menorrhagia in a district general hospital

Practice variation in the stepped care approach to idiopathic heavy menstrual bleeding: A population-based study

INTRODUCTION

Heavy menstrual bleeding (HMB) affects a quarter of all women, with half having no structural cause. Dutch guidelines recommend a stepped care approach to the management of such idiopathic HMB, starting with medication or a levonorgestrel-releasing intrauterine device (LNG-IUD), before progressing to endometrial ablation, and ultimately, hysterectomy. However, practice variation between hospitals could lead to suboptimal health outcomes and increased healthcare costs for some women.

OBJECTIVES

To evaluate adherence to stepped care for women with idiopathic HMB and to identify practice variation among Dutch hospitals.

STUDY DESIGN

This population-based cross-sectional study used Dutch insurance claims data from primary and secondary care for all women with idiopathic HMB referred to a gynecologist between January 2019 and December 2020. We calculated the average number of treatments in the 3 years before each treatment step at each hospital, making adjustments for age, socioeconomic status, and ethnicity. Variation in medical practice was measured by the coefficient of variation (CV).

RESULTS

We studied 20,715 women treated with LNG-IUDs (56%), endometrial ablation (36%), laparoscopic hysterectomy (13%), or vaginal hysterectomy (4%) in 93 hospitals. Before endometrial ablation, on average 47% used medication (hospital range 27%-71%; CV 0.17) and 16% used an LNG-IUD (hospital range 8%-29%, CV 0.32). Before hysterectomy, 52% (hospital range 28%-65%, CV 0.16) used medication, 21% (hospital range 6%-38%, CV 0.35) used an LNG-IUD, and 23% underwent endometrial ablation (hospital range 0%-59%, CV 0.55). On average, women underwent 0.63 (hospital range 0.36-1.00, adjusted rate 0.40-0.98, CV 0.17) and 0.96 (hospital range 0.56-1.45, adjusted rate 0.56-1.44, CV 0.18) treatments before endometrial ablation and hysterectomy, respectively.

CONCLUSIONS

Considerable practice variation exists among Dutch hospitals in the stepped care approach to idiopathic HMB. Improving adherence to this approach could improve quality of care and reduce costs.

Is heavy menstrual bleeding investigated and managed appropriately?

Heavy menstrual bleeding (HMB) accounts for approximately 20% of gynaecology referrals. The National Institute of Clinical Excellence (NICE) recommendations provide the framework for evidence-based management of HMB. Despite this, previous studies have highlighted significant variation in the investigation and management of HMB. This was an observational study of clinical practice performed by retrospective case note reviews of 43 women referred to the Royal Bolton NHS Foundation Trust with HMB between May and June 2011. The care that these women received was evaluated and compared with that currently recommended by clinical guidelines. The investigation and management of HMB in both primary and secondary care was variable, often failing to meet standards recommended by NICE. Greater awareness of NICE guidance may result in improved care. Educational sessions and information provision targeted at healthcare professionals who manage women with HMB, may be beneficial.