Unnecessary hysterectomy: the controversy that will not die

Healthfacts, July, 1993

As long ago as 1948, documented evidence indicated that hysterectomy was an over-performed operation. By the late 1960s, the emerging women's movement helped to focus national attention on the subject, and in 1978, hysterectomy, along with tonsillectomy, became the central issue in a Congressional hearing on unnecessary surgery in the U.S.. The hearing brought to light the fact that there had been no well-designed studies to determine the appropriate indications for either operation, then the two most commonly performed surgical procedures.

In the case of tonsillectomy, a large clinical trial, ongoing at the time of the Congressional hearing, eventually showed that most of the reasons for which children have their tonsils removed are inappropriate; the operation plummeted to 20th on the list of the most commonly performed surgical procedures in the U.S..

There is still no equivalent large-scale clinical trial for hysterectomy. But there have been attempts to determine the degree of overuse. A 1981 Centers for Disease Control study found 15% of hysterectomies were questionable, and a 1990 Blue Cross/Blue Shield of Illinois study showed about one-third to be medically unnecessary. Not until 1989 did the American College of Obstetrician/Gynecologists issue formal guidelines for appropriate indications for hysterectomy.

Although the annual rate has dropped by 100,000 since 1978, hysterectomy remains linked to the charge of abuse. A half a million American women each year continue to undergo the operation; surprisingly, most of them are still in their childbearing years.

The latest study to scrutinize the inappropriateness of hysterectomy involves a comparison of care in seven pre-paid health, or managed care, programs. The study was conducted by the RAND Corporation and published in the Journal of the American Medical Association, (12 May 1993). It is timely, considering that the Clinton Administration is likely to give its blessing to a system called "managed competition."

No doubt, a motivation for the comparison was the prevailing idea that our current fee-for-service medical care system invites abuse because of the physicians' financial incentive to perform procedures. On the other hand, pre-paid medical groups where the physicians are on salary have been criticized for going to the other extreme: withholding care to save money. (If the managed competition idea catches on, we will all have to join a pre-paid medical group.)

But RAND's stated purpose for its hysterectomy study was "to design a method for systematically assessing the quality of care provided in health plans with different organizational and financial characteristics to make information from those assessments publicly available." What they found along the way is that the rate of inappropriate hysterectomy among managed care programs is similar to that of the standard fee-for-service medical care system.

The RAND study began with a random sample of all non-emergency, non-cancer-related hysterectomies performed over a one-year period in seven managed care organizations. The sample was taken only from those women who had been members of their health care programs for at least two years prior to surgery. This is because the care leading up to surgery is crucial to the determination of appropriateness.

An average of 16% of the hysterectomies were judged to be inappropriate (range was 10-27%) and another 24% were of uncertain benefit. An example of an inappropriate indication for hysterectomy is a fibroid tumor smaller than a 12-week fetus with mild bleeding and no pain or discomfort in a woman over age 40. An example of an uncertain indication was mild abnormal uterine bleeding, persistent bleeding between periods, treated with one course of hormonal therapy, and one diagnostic evaluation of the uterine lining in a woman over age 40.

Immediately after the RAND study results were published, its authors issued an additional press release entitled "Important Clarification," intended to correct media reports that apparently had emerged following the first press announcement. "This study contains no data or analysis of fee-for-service practice," according to the Important Clarification. "The results of the study should in no way be used to compare overuse of medical services in fee-for-service care with overuse of managed care."

Co-investigator Robert H. Brook, M.D., head of RAND's health sciences program, stated how the new study results should be interpreted: "This study has a strong message for health care reformers and it is this: If reform does not include measures of quality, the results of this study suggest that there will be large variations in quality of care and that overuse of care will persist. Any serious effort to reform the health care system must systematically address concerns about quality as well as cost control."