The Appropriateness of Recommendations forHysterectomy

MICHAEL S. BRODER, MD, DAVID E. KANOUSE, PhD, BRIAN S. MITTMAN, PhD,

AND STEVEN J. BERNSTEIN, MD, MPH

Objective: To evaluate the appropriateness of recommenda-tions for hysterectomies done for nonemergency and non-oncologic indications.

Methods: We assessed the appropriateness of recommen-dations for hysterectomy for 497 women who had the oper-ation between August 1993 and July 1995 in one of ninecapitated medical groups in Southern California. Appropri-ateness was assessed using two sets of criteria, the firstdeveloped by a multispecialty expert physician panel usingthe RAND/University of California–Los Angeles appropri-ateness method, and the second consisting of the ACOGcriteria sets for hysterectomies. The main outcome measurewas the appropriateness of recommendation for hysterec-tomy, based on expert panel ratings and ACOG criteria sets.

Results: The most common indications for hysterectomywere leiomyomata (60% of hysterectomies), pelvic relaxation(11%), pain (9%), and bleeding (8%). Three hundred sixty-seven (70%) of the hysterectomies did not meet the level ofcare recommended by the expert panel and were judged tobe recommended inappropriately. ACOG criteria sets wereapplicable to 71 women, and 54 (76%) did not meet ACOGcriteria for hysterectomy. The most common reasons recom-mendations for hysterectomies considered inappropriatewere lack of adequate diagnostic evaluation and failure totry alternative treatments before hysterectomy.

Conclusion: Hysterectomy is often recommended for indi-cations judged inappropriate. Patients and physiciansshould work together to ensure that proper diagnostic eval-

uation has been done and appropriate treatments consideredbefore hysterectomy is recommended. (Obstet Gynecol 2000;95:199–205. © 2000 by The American College of Obstetri-cians and Gynecologists.)

Several studies suggested that physicians might usesurgical procedures inappropriately, with some pa-tients not receiving necessary care and others exposedto unwarranted risk.1,2 To improve the quality of pa-tient care, there has been a concerted effort to developguidelines and other criteria for physician practice. Anequivalent effort to implement and disseminate thoseguidelines has been lacking.

The Agency for Health Care Policy and Research, abranch of the US Department of Health and HumanServices, sponsored a series of studies to improve theprocess. One of those studies, the Women’s Health andHysterectomy Project, is designed to develop and dis-seminate recommendations for hysterectomy. We choseto focus this project on hysterectomy because it is thesecond most common major operation women haveand there are significant concerns among researchersand the public that it might be overused.3–5 In thisstudy, we report the appropriateness of recommenda-tions for hysterectomies in a cohort of women at nineSouthern California managed-care organizations beforethe dissemination of clinical recommendations on useof hysterectomy.

Methods

We measured appropriateness of recommendations forhysterectomy using two sets of criteria: 1) a set devel-oped for the Women’s Health and Hysterectomy Projectby an expert panel using the RAND/University ofSouthern California–Los Angeles appropriatenessmethod, and 2) three recent ACOG criteria sets de-

From the Department of Obstetrics and Gynecology, University ofCalifornia, Los Angeles, RAND, Santa Monica, and Veterans Admin-istration Medical Affairs, Sepulveda, California; the Veterans AffairsMedical Center, and the Departments of Medicine and Health Manage-ment and Policy, University of Michigan, Ann Arbor, Michigan.

Funded in part by grant no. R18HS07095 from the Agency for HealthCare Policy and Research, and in part by the Robert Wood JohnsonClinical Scholars Program.

The views expressed herein are those of the authors and do notnecessarily reflect those of the Agency for Health Care Policy andResearch or the Robert Wood Johnson Foundation.

The authors thank the members of the expert panel (Bruce Bagley,Constance Bohon, Vivian Dickerson, Karen Freund, Joseph Gambone,Frank Ling, Anne Moulton, Herbert Peterson, and Marian Swinker) fortheir assistance in developing the ratings, and Stanley Zinberg of ACOGfor assistance with revising the criteria.

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signed “to evaluate the appropriateness of hysterecto-my.”6

The RAND appropriateness method has been welldescribed.1,2,7 For this study, we reviewed the literatureon hysterectomy to examine its efficacy and risks.8

Based on that review, we developed a comprehensivelist of 2332 potential indications for hysterectomy (ex-cluding cancer or emergency) that we divided into eightgroups: leiomyomata, pelvic pain, pelvic relaxation,abnormal uterine bleeding, adnexal mass, cervical dys-plasia, endometrial hyperplasia, and miscellaneous.The indications were composed of explicitly definedfactors necessary for considering hysterectomy (eg,menopausal status, degree of functional impairment,degree of anemia, prior treatment).9

An expert panel of five obstetrician-gynecologists,two internists, and two family physicians was selectedfrom nominations by the relevant specialty societies.The panel included four women and both academic andprivate practitioners. The panelists first independentlyrated the appropriateness of hysterectomy on a 1 to 9scale, with 1 representing a highly inappropriate indi-cation and 9 a highly appropriate one. The paneliststhen met, discussed their ratings, and again indepen-dently rated the indications. The final appropriatenessrating was based on the median of the nine ratings andthe degree of agreement among panelists. If there wasdisagreement among panel members, we considered anindication of uncertain appropriateness. If there was nodisagreement, we considered an indication inappropri-ate if the median panel rating was from 1 to 3, uncertainif the rating was from 4 to 6, and appropriate if therating was from 7 to 9. Details of the panel process werepublished.7

These appropriateness ratings are difficult to use inclinical practice because of their detail and comprehen-siveness. Therefore, they were simplified into a set ofrecommendations for hysterectomy by grouping simi-lar indications with equivalent ratings and eliminatingredundancy. Owing to the absence of outcome data formost indications for hysterectomy, it was not possibleto base those ratings solely on evidence from themedical literature.10 Thus, the recommendations repre-sent the group judgment of the panel regarding appro-priateness of referring for hysterectomy an averagewoman who presents with specific clinical characteris-tics that define an indication. They are not the productof a rigorous risk-benefit analysis because the data forsuch an analysis do not exist. They cannot be followedblindly, nor should they be considered standards ofcare. Rather, they are recommendations, based on evi-dence and experience, for women who are possiblecandidates for hysterectomies. In general, women withindications for which the median panel rating was 4 or

greater (or for which the panel disagreed about the finalrating) were considered possible candidates for hyster-ectomy, whereas those with indications with a medianrating of 3 or less without disagreement were consid-ered inappropriate candidates. For example, the panelconsidered it inappropriate to recommend hysterec-tomy to a premenopausal woman with leiomyomataand bleeding without first evaluating the endometrium(eg, with an endometrial biopsy). In individual casesthere might be other factors crucial to the decision, notincluded in the recommendation, that might influenceappropriateness for a particular woman. The reason formaking the recommendations as comprehensive as pos-sible is to minimize that possibility.10

The ACOG criteria sets were designed to identifycases of hysterectomy that should be peer reviewed. Weused three of the criteria sets as an additional method ofjudging appropriateness of recommendations for hys-terectomy.6,11,12

We identified a convenience sample of nine capitatedmedical groups in Southern California. From thoseorganizations’ member lists we identified 1089 womenwho had hysterectomies between August 1, 1993, andJuly 31, 1995. We excluded 310 women because theprocedure codes for their surgeries did not meet ourcriteria (International Classification of Diseases, 9thRevision, codes 68.3–68.8); surgery was emergent or fora previously diagnosed cancer; or the women did notspeak English, or were cognitively impaired or de-ceased. We obtained informed consent from 539 of theremaining 779 women. An additional 42 were excludedbecause we were unable to obtain all data required toevaluate appropriateness, leaving 497 women. Ninety-seven physicians did the 497 operations. The study wasapproved by the RAND Institutional Review Board. Perinstitutional review board requirements, we collecteddata only on those patients who agreed to participate.

To collect all data necessary to assess the appropri-ateness of the recommendation for hysterectomy, wedid a structured chart review and interviewed eachwoman by telephone. Trained abstractors examinedinpatient and outpatient medical records for each pa-tient and photocopied all admitting and dischargenotes, operative reports, laboratory results, and pathol-ogy reports. Trained nurses conducted telephone inter-views using a prepared script. Before data entry, nurseoverreaders reviewed all forms for completeness andaccuracy. If there was evidence in the medical record orinterview that a woman was offered but refused a givenintervention or medication before her hysterectomy (eg,refusing a laparoscopy) or had a contraindication to aparticular intervention (eg, migraine headaches wors-ened by hormone replacement), that intervention was

200 Broder et al Hysterectomy Recommendations Obstetrics & Gynecology

considered to have been done for the purpose of theappropriateness analysis.

Trained physicians then reviewed the data and as-signed patients to specific diagnostic categories. A com-puter algorithm classified each woman as a possiblecandidate for hysterectomy or as having an inappropri-ate recommendation for hysterectomy based on hermedical characteristics. Each patient could be assignedto multiple diagnoses (eg, a woman with pelvic painand endometrial hyperplasia), and each assignmentreceived an appropriateness rating. When evaluatingappropriateness, a patient was given the highest appro-priateness rating of all the ratings she received.

Two reviewers independently reviewed a 5% (n 5 27)subsample of charts. The kappa statistic was .82 forassignment of diagnostic category and .89 for the finalappropriateness rating, indicating almost perfect agree-ment.13

When ACOG criteria required information we didnot collect (eg, negative cervical cytology before hyster-ectomy for chronic pain), we assumed that all carewould have met that standard. When ACOG listedcriteria without specific definitions, we applied theequivalent definition from the RAND panelists (eg,failure of conservative measures to control symptoms).

We compared the expert panel’s appropriatenessratings and those of ACOG using the x2 statistic. Weconducted several sensitivity analyses, examining howour findings would be affected by inaccuracies in thereporting of symptoms or treatment. We did all statis-tical calculations using Stata statistical software (ver-sion 5.0; Stata Corp., College Station, TX).

Results

Patients had a mean age of 46 years and a median oftwo children (Table 1). Two thirds were white, 14%were Hispanic, and 13% were black. More than half thewomen had household incomes between $31,000 and$75,000 per year. One third had prior tubal sterilization.The study physicians did 375 hysterectomies abdomi-nally (75%), 107 vaginally (22%), and 15 vaginally withlaparoscopic assistance (3%). Of the 97 physicians in thestudy, 30 did one of the hysterectomies, 22 did two orthree, and 17 did ten or more (data not shown).

Three fifths of all hysterectomies were for uterineleiomyomata (Table 2). Women with leiomyomata caus-ing pain accounted for one fourth of all cases, womenwith leiomyomata and bleeding but no pain accountedfor an additional 13% of cases, and women with leiomy-omata and bleeding and pain made up 16% of cases(data not shown).

The percentage of women considered possible candi-dates for hysterectomy varied substantially by clinical

condition (Table 2). For example, only one fifth ofwomen with leiomyomata were considered possiblecandidates for hysterectomy, but more than half ofthose with cervical dysplasia were considered candi-dates. Overall, 70% of cases did not meet the expertpanel’s criteria, and the decision to recommend hyster-ectomy was considered inappropriate. Four commonindications are shown in Table 3.

Most cases for which recommendations for hysterec-tomy were judged inappropriate lacked one or morediagnostic or therapeutic interventions. For example,neither a laparoscopy nor a laparotomy was donebefore hysterectomies on 158 of 204 women (77%) withpelvic pain. The panel believed such an evaluation wasnecessary in most cases to exclude other causes of painbefore hysterectomy. One hundred ten of 246 women(45%) with abnormal uterine bleeding did not have

Table 1. Demographic and Clinical Characteristics

Characteristic No. of cases % of cases

Age (y),40 94 1940–49 272 5550–59 82 16.59 49 10

No. of children0 89 181 94 19$2 313 63

RaceWhite 324 65Hispanic 68 14Black 63 13Other 42 8

Menopausal statusPremenopausal 403 81Postmenopausal 94 19

Annual income,$10,000 9 2$10–30,000 115 23$31–50,000 144 29$51–75,000 124 25.$75,000 88 18

Employment statusFull-time 333 67Part-time 45 9Unemployed 45 9Retired 35 7Homemaker 40 8

Highest education levelDid not complete high school 30 6High school 144 29Some college 199 40College graduate 124 25

Marital statusMarried 342 69Never married 40 8Widowed, divorced, separated 114 23

VOL. 95, NO. 2, FEBRUARY 2000 Broder et al Hysterectomy Recommendations 201

endometrial sampling before hysterectomy. Seventy-one of 340 women (21%) with pain or bleeding did notreceive (or were not offered) a trial of medical treatmentfor pain or bleeding. In one third of cases that requiredintervention, two or more interventions were omitted.

Of 497 women we studied, 71 had hysterectomies for

endometriosis, chronic pelvic pain, or premenopausalabnormal bleeding, conditions covered by three recentACOG criteria sets. The recommendation for hysterec-tomy was judged inappropriate for 53% of that subsetof women by the expert panel criteria and 76% of thosedid not meet ACOG criteria (Table 4). Although ACOGcriteria sets explicitly state that required data should befound in the medical record, we also used data foundonly in patient interviews.

Inadequate medical records or faulty patient recallmight lead to incorrect analyses, so we conducted twosensitivity analyses. The women in this study did nothave hysterectomies for cancer or emergencies, so theirsurgeries were primarily done to improve the quality oftheir lives. As a result, the expert panel usually requiredevidence that a woman suffered some type of impair-ment of daily function to be a possible candidate forhysterectomy. If we assumed that all women wereimpaired, the percentage of cases judged inappropri-ately recommended fell from 70% to 66%. The high rateof inappropriate recommendations for hysterectomiesdespite significant impairment was because women hadnot had diagnostic or therapeutic interventions thatwere considered necessary before hysterectomy. Docu-mentation and recall of medication use might be lessaccurate than recall of procedures, so we examined theeffect of assuming that all women had trials of medicaltreatment before surgery. In that case, the inappropriaterate fell to 66%.

Discussion

We found that the care leading recommendations ofhysterectomies in our cohort was suboptimal. Seventypercent of those cases did not meet standards of expertpanel recommendations. In addition, 76% of women

Table 2. Appropriateness of Recommendations for Hysterectomy by Diagnostic Category

Diagnosis

Total no. ofhysterectomies

Appropriateness rating*

Possible candidate Inappropriate

No. %† No. %‡ No. %‡

Leiomyomata 298 60 64 21 234 79Pelvic relaxation 55 11 24 44 31 56Pain 45 9 23 51 22 49Abnormal bleeding 41 8 18 43 23 57Cervical dysplasia 20 4 11 55 9 45Adnexal mass 22 4 6 27 16 73Endometrial hyperplasia 10 2 3 30 7 70Miscellaneous 6 1 0 6 100

Total§ 497 99 130 30 367 70

* Appropriateness for cases with multiple indications based on highest (most appropriate) rating.† Column percentage.‡ Row percentage.§ Percentages may not add to 100 because of rounding.

Table 3. Common Indications for Hysterectomy by PanelRating

IndicationNo. ofcases

% of allcases

Possible candidate for hysterectomyPremenopausal woman with leiomyomata

and bleeding without pain who had atrial of medical therapy (or was offeredand refused such a trial); has significantanemia or major impairment frombleeding; and has no significant diseaseon endometrial sampling

12 2

Postmenopausal woman with persistentor recurrent abnormal bleeding whohas been given a trial of hormonetherapy (or had hormone therapyadjusted) and has no significant diseaseon endometrial sampling

10 2

InappropriatePremenopausal woman with

leiomyomata, bleeding, and pain whohas significant anemia or majorfunctional impairment but has notundergone endometrial sampling

44 9

Premenopausal or postmenopausalwoman with cervical intraepithelialneoplasia 2 confirmed by biopsywithout trial of conservative treatment(eg, loop electrosurgical excisionprocedure/large loop excision of thetransformation zone, cryotherapy, orconization)

5 1

202 Broder et al Hysterectomy Recommendations Obstetrics & Gynecology

with conditions covered by ACOG criteria sets wouldhave been referred for peer review because their caredid not meet ACOG criteria.

Our finding that many diagnostic steps are not donebefore hysterectomy is not unique. In the Maine Wom-en’s Health Study, fewer than half of women withabnormal uterine bleeding had endometrial samplingbefore hysterectomy and only two thirds of those withpelvic pain had prehysterectomy laparoscopies.14 Ourfindings do not mean that had all the recommendedsteps been followed only 30% of the hysterectomieswould have been done. Several frequently omitteddiagnostic or treatment steps necessary for women to beconsidered possible candidates for hysterectomy prob-ably would not have affected the eventual outcome. Forexample, endometrial sampling is often done to rule oututerine cancer, but hysterectomy is commonly doneregardless of the results of that sampling. The expertpanel ratings and ACOG’s criteria sets provided anobjective standard by which the quality of recommen-dations for hysterectomy could be judged, and canprovide a benchmark with which to compare care in avariety of settings.

The rate of inappropriate recommendations for hys-terectomy in this study is higher than the rates reportedfor coronary angiography, tympanostomy tubes, andupper gastrointestinal endoscopy, which have rangedfrom 2% to 44%; however, it is in the range found forcarotid endarterectomy.2,15–17 It is also significantlyhigher than the 10–27% inappropriate rates found forhysterectomy in previous studies of managed careorganizations using similar methodology.4 However,the previous study examined appropriateness of theprocedure itself, rather than the recommendation forhysterectomy. In the current study, 14% of women hadclinical characteristics such that, regardless of diagnos-tic or therapeutic steps before surgery, the panel wouldhave considered the procedure inappropriate (eg, sur-gery for pelvic relaxation in a woman with first-degreeuterine prolapse and no incontinence or pain). Themajority of recommendations for hysterectomy werejudged inappropriate, so we must consider whether ourcriteria were too strict, or if the appropriateness method

itself was flawed. We believe our criteria were reason-able for several reasons. A national, multispecialty,expert panel developed the criteria using a well-established methodology.15–18 For example, Shekelle etal found moderate reliability (ie, k 5 .51) across threeexpert panels who rated appropriateness of hysterec-tomy using identical methodology.19 That level of reli-ability is significantly better than individual surgeonsregarding need for hysterectomy.20 Significantly morecases met our own panel’s criteria than those inACOG’s criteria sets, which might have been becauseour criteria were biased toward fewer inappropriateratings than ACOG criteria (ie, we classified cases withmultiple indications by the indication with the highestappropriateness score). We ignored whether criticalsteps were followed for other indications. Using theexpert panel ratings, a woman with chronic pelvic painand abnormal bleeding could have been considered apossible candidate for hysterectomy for pain, despiteinadequate evaluation for bleeding. The ACOG hyster-ectomy criteria set for chronic pain, on the other hand,requires that if bleeding is present, it must also beproperly evaluated.6 In cases in which a particulartherapy or intervention was required before hysterec-tomy, our rules reduced the number considered inap-propriate by accepting evidence that women were of-fered such treatment as the equivalent of actuallyreceiving it.

Our findings depended on how accurately we mea-sured the care the women received, so we took severalsteps to enhance the accuracy and completeness of thedata. We obtained all relevant in- and outpatientrecords. We conducted independent abstractions for asubsample of women and showed excellent inter-raterreliability. We also interviewed each woman, collectingdata not routinely reported in the medical record. Weconducted sensitivity analyses and found that our re-sults would not be materially affected even by largeerrors in recording data, such as use of medical therapyor degree of impairment.

Our data appeared to be accurate and the standardsfor assessing appropriateness of recommending hyster-ectomy reasonable, so what caused the large difference

Table 4. Hysterectomy Appropriateness Judged by Expert Panel Recommendations and by ACOG Criteria Sets

ConditionNo. ofcases

Cases that did not meet criteria

P

Expert panel ACOG

No. % No. %

Endometriosis 23 4 17 15 65 ,.001Premenopausal abnormal uterine bleeding 31 18 58 22 71 .210Chronic pelvic pain 17 16 94 17 100 .150

Total 71 38 53 54 76 ,.001

VOL. 95, NO. 2, FEBRUARY 2000 Broder et al Hysterectomy Recommendations 203

between actual practice and those standards? There areseveral potential answers. Hysterectomy is a relativelysafe procedure that effectively cures abnormal uterinebleeding and often resolves other gynecologic symp-toms.14,21 Thus, many women or their physicians mightperceive that the benefits of hysterectomy outweigh itsrisks, even in situations when the panel felt that therisk/benefit ratio suggested otherwise. The lack ofrandomized controlled trials (RCTs) that evaluated hys-terectomy might lead to professional uncertainty aboutindications for hysterectomy. When our panel met,there was only a single RCT that compared hysterec-tomy to an alternative treatment for menorrhagia, andnone that compared it to alternative treatments forleiomyomata.22 Reimbursement policies (eg, payingmore for surgery than medical treatment) might con-tribute to the gap between clinical practice and therecommendations.

There were several limitations to this study. We couldnot identify underuse of hysterectomy. Although wefound underuse of medical treatment and conservativesurgeries among women who eventually had hysterec-tomies, we did not examine care for women with thesame gynecologic conditions who did not undergohysterectomy, and there might be substantial underuseamong those women.

Our study focused on practices in Southern Califor-nia during a 2-year period, and the results might not begeneralizable to other regions or times. Rates of hyster-ectomy vary markedly across regions, and it is notknown whether the proportion of women who receiveinappropriate recommendations for hysterectomy alsovaries by region.23–25 In addition, care might varyamong physicians; however, the hysterectomies exam-ined in this study were done by 97 physicians workingat nine different medical groups, and the majority ofthem did three or fewer hysterectomies in the study.Thus, this study did not represent the care of only a fewphysicians. After controlling for diagnosis, there wereno significant differences among medical groups withregard to appropriateness ratings. We had too few casesper physician to examine a specific physician effect.

The recommendations used in this study representthe group judgment of experts (the expert panel andACOG) on the appropriateness of recommendations forhysterectomy for the average woman who presentedwith specific clinical characteristics. The recommenda-tions were designed to examine the care given topopulations of patients, not individual women, and thecriteria sets were designed to identify cases that shouldbe peer reviewed. These types of ratings can best bethought of as screening tests that suggest the need forphysician review of cases not meeting guidelines.19

Studies such as this can be useful for internal and

external quality evaluations. For example, we foundsubstantial evidence of underuse of established diag-nostic and therapeutic regimens before proceeding tohysterectomy. We are working with the medical plansto determine whether providing this information to thephysicians will improve the quality of care for womenwith conditions leading to hysterectomy.

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21. Dicker RC, Greenspan JR, Strauss LT, Cowart MR, Scally MJ,Peterson HB, et al. Complications of abdominal and vaginalhysterectomy among women of reproductive age in the UnitedStates. The Collaborative Review of Sterilization. Am J ObstetGynecol 1982;144:841–8.

22. Gannon MJ, Holt EM, Fairbank J, Fitzgerald M, Milne MA, CrystalAM, et al. A randomized trial comparing endometrial resectionand abdominal hysterectomy for the treatment of menorrhagia.BMJ 1991;303:1362–4.

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Address reprint requests to:Michael S. Broder, MDDepartment of Obstetrics and GynecologyUCLA School of MedicineBox 951740Los Angeles, CA 90095-1740E-mail: mbroder@ucla.edu

Received February 24, 1999.Received in revised form July 21, 1999.Accepted August 5, 1999.

Copyright © 2000 by The American College of Obstetricians andGynecologists. Published by Elsevier Science Inc.

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