Contemporary treatment utilization among women diagnosed with symptomatic uterine fibroids in the United States – BMC Blogs Network

Patient characteristics

A total of 225,737 and 19,062 women with 12months post-index eligibility met the inclusion criteria for symptomatic UF in the Commercial and Medicaid databases, respectively (Table1). For the 12-month follow-up group, the mean (SD) age was 43.0 (7.1) years for the Commercial population and 38.9 (7.8) years for the Medicaid population. In the Commercial population, 44.6% of women resided in the South geographic region. In the Medicaid population, black women comprised 59.7% of the study population. The most common insurance plan types were HMOs (57.1%) in the Commercial population and PPOs (57.9%) in the Medicaid population. Demographics for the 60-month follow-up cohort were broadly similar to those reported for the 12-month follow-up cohort in both populations (data available upon request).

In the 12months post-index, bulk symptoms were the most common symptom (Commercial, 44.8%; Medicaid, 72.5%), with pelvic pressure/pain most frequently reported, while the most common fibroid-related co-morbidity was urinary tract infection (Commercial, 8.1%; Medicaid, 20.0%) (Table1).

Women with symptomatic UF had mean (SD) Elixhauser co-morbidity summary scores of 1.9 (3.4) (Commercial) and 5.7 (6.3) (Medicaid) in the 12-month post-index period, and mean (SD) Deyo-Charlson Index summary scores of 0.2 (0.6) and 0.6 (1.1), respectively (Table1).

Between 2010 and 2015, the diagnosed prevalence of symptomatic UF ranged from 0.570.89% for the Commercial population. Between 2009 and 2015, the diagnosed prevalence ranged from 0.440.51% for the Medicaid population. The Commercial population had a 6-year cumulative incidence of 1.23% (343,341 cases from 2010 to 2015) and the Medicaid population had a 7-year cumulative incidence of 0.64% (32,525 cases from 2009 to 2015).

For the 12-month follow-up, initial treatments for Commercially insured women with symptomatic UF were divided relatively equally between surgical (36.7%), pharmacologic (31.7%), and no treatment (31.6%), whereas for Medicaid-insured women with symptomatic UF, the majority of women received pharmacologic treatment (53.0%), followed by surgical (28.7%) and no treatment (18.3%) (Figs.2 and 3). Overall, the most common initial pharmacologic treatments were NSAIDs (15.7% [n=35,489] and 32.8% [n=6253] in the Commercial and Medicaid populations, respectively), followed by hormonal contraceptives (12.5% [n=28,315] and 10.6% [n=2029]). The most common initial surgical treatment was hysterectomy (Commercial, 24.8% [n=56,072]; Medicaid, 21.8% [n=4125]), followed by myomectomy (5.7% [n=12,814]) in the Commercial population and ablation (4.0% [n=756]) in the Medicaid population.

Treatments and time to treatment for the Commercial cohort; 12-month follow-up. aIncludes IUD/levonorgestrel implants, oral contraceptives, and other contraceptives; hormonal contraceptives were not mutually exclusive and a patient could receive >1 type. bDoes not include women with hysterectomy as first-line procedure. GnRH: gonadotropin-releasing hormone; IUD: intrauterine device; NSAID: non-steroidal anti-inflammatory drug; SD: standard deviation; SERM: selective estrogen receptor modulator

Treatments and time to treatment for the Medicaid cohort; 12-month follow-up. aIncludes IUD/levonorgestrel implants, oral contraceptives, and other contraceptives; hormonal contraceptives were not mutually exclusive and a patient could receive >1 type. bDoes not include women with hysterectomy as first-line procedure. GnRH: gonadotropin-releasing hormone; IUD: intrauterine device; NSAID: non-steroidal anti-inflammatory drug; SD: standard deviation; SERM: selective estrogen receptor modulator

In the 12months post-index, nearly half of women (Commercial, 41.1%; Medicaid, 49.1%) who received an initial pharmacologic or surgical treatment received a second treatment. Among Commercially insured women who received an initial pharmacologic treatment, 40.5% received a second treatment, most commonly surgery (56.3%), of whom 56.7% received a hysterectomy (Fig.2). Among Commercially insured women who received surgery as initial treatment, 42.8% received a second treatment, most commonly pharmacologic treatment (89.3%) (Fig.2). In the Medicaid population, a second treatment was received by 47.5% of those who received an initial pharmacologic treatment and 61.1% of those who received an initial surgical treatment; pharmacologic treatment was the most common second treatment in both groups (63.8 and 89.6%, respectively) (Fig.3).

Injectable NSAID use, within 7days before or after any surgical treatment, was low for symptomatic UF (Commercial, <0.1%; Medicaid, 0.2%). GnRH agonist use was low at any time before (Commercial, 0.7%; Medicaid, 0.4%) or after (Commercial, 1.0%; Medicaid, 0.6%) any initial surgical treatment for symptomatic UF.

Among Commercially insured women with symptomatic UF, 25,771 women received oral contraceptives as initial treatment, of whom 5157 (20.0%) received a second treatment of surgery in the 12months post-index. Of the 226 women who received an IUD as initial treatment, 24 women (10.6%) received surgery as a second treatment. Among Medicaid-insured women with symptomatic UF, 1613 women received oral contraceptives as the first treatment, of whom 196 (12.2%) received surgery as the second treatment, while 50 women received an IUD as initial treatment, of whom three (6.0%) received surgery as a second treatment.

Mean (SD) time from index date to first treatment was 56.5 (82.0) days (Commercial) and 54.8 (79.8) days (Medicaid), while time from index date to second treatment was 101.9 (100.5) days and 104.7 (99.6) days, respectively. Times to first surgical treatments were generally shorter than times to first pharmacologic treatments (Figs.2 and 3).

Among Commercially insured women with symptomatic UF presented by age, mean (SD) time to first treatment ranged from 53.1 (78.3) days (age 4044years) to 76.7 (96.9) days (age 5559years); time to first pharmacologic treatment generally increased with age, while time to first surgery remained largely consistent across the age groups (Table2). For Medicaid-insured women with symptomatic UF, mean (SD) time to first treatment ranged from 51.5 (76.5) days (age 3539years) to 86.4 (98.6) days (age 6064years); time to first pharmacologic treatment and time to first surgery remained generally consistent across the age groups (Table2). Time from index date to second treatment tended to decrease with age in both populations (Table2).

Mean (SD) time to first treatment was shorter for women who received contraceptives in the 12months pre-index (Commercial: 36.1 [59.9] days; Medicaid: 40.6 [66.8] days) compared to those who did not (Commercial: 62.8 [86.6] days; Medicaid: 57.9 [82.0] days); this pattern remained consistent for time to first pharmacologic treatment or surgical treatment (see Table S2, Additionalfile2). Time from index date to second treatment was similar among those who did or did not receive contraceptives in the 12months pre-index in both populations (see Table S2, Additionalfile2).

Mean (SD) time to treatment was similar across UF-related symptoms, ranging from 48.6 (74.0) to 58.1 (81.8) days (Commercial) and 46.1 (69.1) to 54.1 (78.8) days (Medicaid) (see Table S3, Additionalfile3).

Proportions of women receiving any treatment in the 12months post-index decreased with increasing age (Table2). The proportion of women receiving any pharmacologic treatment decreased slightly with increasing age, while the proportion of women receiving any surgical treatment peaked at age 4044years. Uterine-sparing surgery (myomectomy, UAE, ablation, and myomectomy and ablation combined) peaked at age 2529years (Commercial, 25.7% [n=1410]) and 4044years (Medicaid, 13.8% [n=598]). In the Commercial population, the most common treatments were NSAIDs for all age groups (27.040.4%), except 1824years and 2529years, where hormonal contraceptives were the most common (54.1 and 42.9%, respectively). The second most common treatments were NSAIDs in women aged 1824years (32.2%) and 2529years (39.9%), hormonal contraceptives in women aged 3034years (31.6%), and hysterectomy for all age groups 35years (15.936.7%). In the Medicaid population, the most common treatments among all age groups were NSAIDs (54.164.7%), followed by hormonal contraceptives for age groups 1824years and 2529years (43.5 and 35.1%, respectively), and hysterectomy for all age groups 30years (16.636.3%).

Women with contraceptive use in the 12months pre-index were more likely to undergo any treatment during the 12months post-index compared to women with no pre-index contraceptive use (Commercial, 90.4% versus 63.6%; Medicaid, 91.1% versus 79.9%) (see Table S2, Additionalfile2).

Treatment utilization according to symptomatology was similar to that observed in the overall population, with NSAIDs (Commercial, 43.849.6%; Medicaid, 66.570.6%) and hysterectomy (Commercial, 36.656.6%; Medicaid, 34.151.8%) the most common treatments received in the 12months post-index. Women with anemia were more likely to undergo hysterectomy (Commercial, 56.6%; Medicaid, 51.8%) compared to women reporting other symptoms (Commercial, 36.645.7%; Medicaid, 34.143.2%) (see Table S3, Additionalfile3).

Among women with longer continuous enrollment, the proportion of women receiving any treatment increased over the 60-month (5-year) follow-up, from 68.4% after 12months to 86.3% (Commercial) and from 81.7 to 95.7% (Medicaid) (see Fig. S1, Additionalfile4). The most common treatments by age group were similar for women with 12- and 60-month follow-up, with NSAIDs the most common treatment, followed by hysterectomy and hormonal contraceptives (data available upon request).

Of procedures of abdominal hysterectomy, abdominal myomectomy, UAE, and ablation in the first 12months post-index, 14.9% (Commercial, n=15,783/105,896) and 24.9% (Medicaid, n=1982/7960) resulted in a treatment-associated complication. Abdominal hysterectomy was the most common surgical treatment for which complications were recorded (Commercial, 64.4% [n=68,166]; Medicaid, 73.3% [n=5832]), and was associated with the highest complication rates (18.5% [n=12,603] and 31.0% [n=1806], respectively). Post-operative adhesions (pelvic peritoneal; ICD-9614.6, ICD-10N994) were the most commonly reported complication among those women who received an abdominal hysterectomy (Commercial, 9.5% [n=6464]; Medicaid, 14.3% [n=835]), followed by urinary tract infection (Commercial, 3.2%; Medicaid, 7.8%) and wound infection (Commercial, 1.6%; Medicaid, 4.6%). The overall mortality rate associated with abdominal hysterectomy was 0.36% (Commercial, 0.29%, n=199; Medicaid, 1.17%, n=68).

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Contemporary treatment utilization among women diagnosed with symptomatic uterine fibroids in the United States - BMC Blogs Network

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