Regional variation of hysterectomy for benign uterine diseases in Switzerland

PLoS One. 2020 May 14;15(5):e0233082. doi: 10.1371/journal.pone.0233082. eCollection 2020.

Abstract

Background: Hysterectomy is the last treatment option for benign uterine diseases, and vaginal hysterectomy is preferred over more invasive techniques. We assessed the regional variation in hysterectomy rates for benign uterine diseases across Switzerland and explored potential determinants of variation.

Methods: We conducted a population-based analysis using patient discharge data from all Swiss hospitals between 2013 and 2016. Hospital service areas (HSAs) for hysterectomies were derived by analyzing patient flows. We calculated age-standardized mean procedure rates and measures of regional variation (extremal quotient [EQ], highest divided by lowest rate) and systematic component of variation [SCV]). We estimated the reduction in the variance of crude hysterectomy rates across HSAs in multilevel regression models, with incremental adjustment for procedure year, age, cultural/socioeconomic factors, burden of disease, and density of gynecologists.

Results: Overall, 40,211 hysterectomies from 54 HSAs were analyzed. The mean age-standardized hysterectomy rate was 298/100,000 women (range 186-456). While the variation in overall procedure rate was moderate (EQ 2.5, SCV 3.7), we found a very high procedure-specific variation (EQ vaginal 5.0, laparoscopic 6.3, abdominal 8.0; SCV vaginal 17.5, laparoscopic 11.2, abdominal 16.9). Adjusted for procedure year, demographic, cultural, and sociodemographic factors, a large share (64%) of the variance remained unexplained (vaginal 63%, laparoscopic 85%, abdominal 70%). The main determinants of variation were socioeconomic/cultural factors. Burden of disease and the density of gynecologists was not associated with procedure rates.

Conclusions: Switzerland has a very high regional variation in vaginal, laparoscopic, and abdominal hysterectomy for benign uterine disease. After adjustment for potential determinants of variation including demographic factors, socioeconomic and cultural factors, burden of disease, and the density of gynecologists, two thirds of the variation remain unexplained.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Cultural Characteristics
  • Demography
  • Female
  • Humans
  • Hysterectomy / methods*
  • Hysterectomy / statistics & numerical data
  • Hysterectomy, Vaginal / statistics & numerical data
  • Laparoscopy / statistics & numerical data
  • Middle Aged
  • Regression Analysis
  • Rural Population
  • Socioeconomic Factors
  • Switzerland
  • Urban Population
  • Uterine Diseases / surgery*
  • Young Adult

Grants and funding

This research project was supported by the National Research Program 74 of the Swiss National Science Foundation (SNSF), Grant number SNSF 407440_167339: DA, MW, RP, AC, NR Health Services Research funding program of the Gottfried and Julia Bangerter-Rhyner-Stiftung and the Swiss Society of General Internal Medicine Foundation: DA, NR, AC. The sponsors did not have influence on the study design, the collection, analysis and interpretation of the data, the writing of the report, and in the decision to submit the manuscript for publication.