Treatment options for EPF include expectant management, medical completion with misoprostol, and surgical evacuation in either an office or operative suite. Treatment patterns in Michigan do not appear to reflect either evidence-based practices2–13
or patient preferences.14,17–19
Rather, this study suggests that women in Michigan are typically managed either expectantly or with surgical uterine evacuation in an operating room. Our findings also suggest patient factors, such as age and race, may be associated with treatment type, which has important implications for improving clinical care. The main factor determining treatment patterns, however, is most likely having access to providers offering a range of treatment options.
Few studies have examined treatment preferences among patients seen for EPF. Graziosi et al.18
interviewed women diagnosed with EPF about their views on medical treatment with misoprostol as compared to suction curettage. About 50% of women interviewed would choose medical management if its success rate exceeded 65%. Other studies have indicated that many women prefer to avoid general anesthesia for uterine evacuations.20,21
Our previous work suggests almost half of women will choose to have their uterine evacuation completed in an office setting.14
Based on these few studies, one would expect a greater proportion of cases than was identified in our study population to be managed with misoprostol or office uterine evacuation.
Although this study was primarily designed to examine overall treatment patterns, we found that women in the local university-affiliated health plan are much more likely to have an office uterine evacuation than women enrolled in Medicaid. We believe that the main explanation for this treatment difference is that members of the university-affiliated health plan have access to a network of providers offering this service, whereas women in other parts of the state do not. It is also possible that particular populations, such as low-income or minority women, do not accept office procedures to the same degree as women in the university-affiliated system, but our study cannot assess such differences.
Although we were not surprised to find that office uterine evacuations were uncommonly used, our previous work with women experiencing EPF concluded that office procedures are acceptable and sometimes preferable over the same procedure in an operating room.14,19
After office uterine evacuations were introduced into our health system, there was a surge of referrals indicating a high level of enthusiasm. Over time, use decreased slightly as patients and providers became familiar with the benefits and limitations of office procedures. Clearly, moving even some procedures out of an operating suite offers substantial cost savings.1,14,22
Still, a wide range of obstacles or disincentives probably limit the availability of office uterine evacuations, including discomfort with office procedures in general or a lack of perceived demand for such service. It is also possible that office uterine evacuations for EPF are uncomfortably similar to induced abortions, and some providers are reluctant to add the service to their practice.23
Two identified trends could reflect the recent adoption of newer treatment options by providers. First, the rate of surgical treatment increased significantly over the study period among the members of the university-affiliated health plan. This trend occurred immediately after office uterine evacuations were made widely available in this system. Because the service is convenient to patient and providers, we anticipated that it would move some patients out of the operating room into the clinic for their procedure. However, its addition may have effectively increased access to surgical treatment generally, resulting in more patients undergoing surgical completion as opposed to expectant or medical treatment. Increasing the rate of surgical intervention may not improve the quality of EPF care. Second, although misoprostol use was rare, its use appeared to be increasing over the study period, which may reflect early adoption of this treatment option. How the addition of misoprostol treatment will change overall treatment patterns is uncertain.
Patient race and age were associated with being treated with a surgical procedure among our study sample, which has not been described previously. Although African American women and Hispanic women were more likely to have a complete abortion based on ICD-9 coding, this study could not assess how much of the disparity was explained by this difference. It may be that these groups had a harder time accessing care and, therefore, sought care after spontaneous passage of products had already occurred. Alternatively, there may be community-based influences causing treatment preference differences between these groups. Our study could not explain these findings, but these treatment differences warrant further study.
After EPF, women express strong treatment preferences,24
yet providers still influence ultimate treatment choice.14,17
Although we found no study comparing treatment preference or acceptance among women presented with all options, several studies provide evidence that women will accept the range of options addressed in this study.14,17–19,24,25
It is unlikely that treatment patterns in Michigan only reflect patient preference. Expanding treatment options to reflect patient preferences and evidence-based practices could both improve patient-centered care and possibly decrease healthcare resource use. However, changing clinical practices is a complex challenge. Previous work consistently shows that adherence to evidence-based practices is suboptimal.26–29
A number of identified barriers to practice change might have particular significance in EPF care, such as a lack of confidence that one can actually perform the behavior or a belief that patients will not accept the change.27
A better understanding of the existing barriers to changing clinical practices is needed to effectively encourage providers to broaden treatment choices for women experiencing EPF.
Our study methodology has several limitations. First, this methodology cannot explain the reasons underlying the identified treatment patterns, including associations with patient race or socioeconomic status. We also could not distinguish between patients who began with expectant management but went on to have a surgical uterine evacuation and those who primarily elected to have surgery. Further, administrative codes are often difficult to interpret, misclassification is common, and we would likely misclassify those who went outside their insurance plan for treatment. For instance, we doubted that the distinction between cases that were coded as complete vs. incomplete abortions was very accurate; therefore, we do not comment on the appropriateness of the relatively high number of surgical interventions done in the complete group. We also found that >10% of women identified as having an EPF by diagnosis code had no evidence of it upon chart review. Still, our classification scheme was able to determine treatment type with a high degree of accuracy, which was our primary objective. We opted not to attempt to correct for this bias in the larger database for two reasons. First, it is possible that the university-affiliated system is more likely to see these cases because of referral patterns. Second, we were primarily interested in validating our methods of treatment classification, which was not affected by these cases. Still, some degree of similar misclassification would probably be present in other data sources as well. Based on our findings, this bias would likely increase the apparent proportion of cases managed expectantly.
We anticipated some difficulty in determining procedure location, which was somewhat confirmed during our validation process. Our validation process indicated that we overestimated the proportion of cases done in an office, at least among enrollees of the university-affiliated health plan. We also could not assess why a patient was prescribed misoprostol, and it is possible that it was used for another indication, such as hemorrhage. Again, this misclassification would overestimate the proportion of cases managed medically. Given the rarity of both office uterine evacuations and misoprostol use among Medicaid enrollees, it is unlikely that the presence of these biases changes our study's fundamental conclusions. Alternatively, it is possible that some providers dispense misoprostol in their office, which would not have been identified by our methods. We know that misoprostol is not being dispensed from offices in the university-affiliated health plan and suspect that this practice is uncommon elsewhere in the state.