Leiomyoma-related inpatient care is substantial and predicted to increase significantly by 2050. Approximately 42 per 10,000 women, aged 15–54, are hospitalized annually for leiomyoma-related treatments. Major surgery, including hysterectomy and myomectomy, occurs in the majority of these hospitalizations. Such leiomyoma-related health care events appear, from this data, to occur much more often in black women than in white women. Given the increasing population and the projected increasing diversity and changing demographics of the US population16
the absolute magnitude of this common female health problem will increase 20 to more than 30% by the year 2050. If current trends continue, there will be more than 400,000 leiomyoma-related hospitalizations in 2050 with the associated morbidity and cost. Because indirect costs (disability and absenteeism) are a significant proportion of the health care costs for leiomyoma, these trends could also have substantial implications for workforce productivity.3,6
Uterine leiomyoma have a differential impact for black women for several reasons. 1
Incidence rates for black women are 2- to 3-fold higher than for white women.9,17
Black women, as compared with white women, are more likely to be hospitalized and to have a hysterectomy for fibroids; they are much more likely to have a myomectomy. They are also more likely to have a more severe disease at the time of presentation and the time of surgery as well as a higher prevalence and relative risk of fibroids.9,18–20
Finally, leiomyomas affect black women over a wider age span with an earlier age of onset and no growth deceleration as women approach menopause.18,21
These factors magnify the importance of the changes anticipated by this study.
Our results point toward an increasing financial burden related to leiomyoma-related inpatient care for our country’s future. Health care costs related to leiomyoma are already high; costs for total health care and for inpatient care in women with fibroids are 2.6 times and 6.6 times those for women without fibroids. 3
Inpatient stays, generally 2–3 days for leiomyoma care, represent a large part of treatment costs.6,22
Inpatient myomectomy costs $5425–11,839 and inpatient hysterectomy costs $5012–7934 in 2004 dollars.23
Using data from 1999–2004, leiomyoma-related direct (medical) and indirect (productivity) costs for women 25–54 with symptomatic leiomyoma were examined: direct 12-month costs were $11,720 for women with leiomyoma, compared with $3257 for women without such leiomyoma, and indirect health-related costs over a year were an additional $11,752 compared with $8083 for controls (P
Other costs (pregnancy complications, infertility, urinary symptoms) are not easily represented or measured, but are substantial.3
Furthermore, myomectomy and other uterine-sparing treatments are likely to increase as more women delay childbearing or opt for minimally invasive procedures such as uterine artery embolization. These treatments are not infrequently followed by additional medical symptom management, UAE, repeat myomectomy, and hysterectomy, compounding the overall per-person cost for fibroid-related care.
Conclusions from this study must be evaluated within the context of its limitations. One limitation is the number of necessary assumptions. We assume that the rates of hospitalizations, hysterectomies, and myomectomies going forward will remain similar to 2007 rates. This assumption is supported by Whiteman et al,24
using NIS data to demonstrate no significant change in leiomyoma-related hospitalizations over 7 years to 2005. Given the importance of racial difference in the impact of uterine leiomyoma, we chose to analyze and report difference by black and white race, despite awareness that race data in the NIS is incomplete. Our calculations are valid only under the assumption that black and white race categories are equally likely to have missing data. We intend the race data and predictions from this data only to stimulate discussion and further research in this arena; yet our findings are not incongruous with known increased prevalence and fibroid burden born by black women but also previous research suggesting that black women are more likely to undergo major surgery for fibroids.17,25
Age differences in this data are presented without complex analysis to identify statistical differences among age and race categories. Though rates of events differed somewhat by age, age standardization in similar studies did not make a significant difference to overall rates.7
The NIS uses only ICD-9 codes, and the ICD-9 codes available to identify myomectomy are nonspecific and may miss some procedures or include nonspecific uterine surgery not myomectomy. The data were also searched by using ICD-9 codes 68.29 with 69.19, resulting in minimal change in estimates of myomectomy numbers and rates. Also, the ICD-9 codes we used to identify hysterectomy may include surgeries performed for gynecologic cancer with leiomyoma as a secondary finding.
Our calculated rates likely underestimate total leiomyoma-related health care delivery for a number of reasons. The NIS does not capture treatments associated with admission not designated as inpatient. This would exclude from the NIS data most minimally invasive fibroid treatments: laparoscopic, robotic, and many vaginal hysterectomies, nearly all hysteroscopic myomectomies, and most UAE, not to mention MRgFUS. Also important is that estimates of hysterectomy rates, including ours, do not routinely correct for the number of women in the population who have already had hysterectomies and are therefore no longer “at risk” for the outcome (ie, they should not be in the denominator for calculating rate), making the estimated rates artificially lower than actuality.26
A major strength of this study is that the 2007 Nationwide Inpatient Sample is a reliable and recent source, and in fact, the best available data on leiomyoma-related US hospitalizations, hysterectomies, and myomectomies. US Census Bureau predictions for future population size and demographics are readily available. The combination of these data sources represents a new application of a proven strategy to illustrate the predicted current and future impact of leiomyoma-related inpatient care, a critically important women’s health issue.27
Our conclusions are supported by similar analyses in the literature, though reported rates of inpatient leiomyoma care are lower if inclusion is limited to leiomyoma only as the principal diagnosis. Though arguably less specific, we include all patients with diagnoses of leiomyoma to include those patients whose principal diagnosis may have leiomyoma as the underlying disease process (eg, abnormal uterine bleeding).
Symptomatic uterine leiomyoma are a critical issue in women’s health. Common and with an often devastating impact on quality of life, leiomyoma are also a primary source of resource consumption. Inpatient care and major surgery for uterine leiomyoma remains substantial despite advances in less-invasive treatment options. Assuming stable rates of hospitalization and surgery, this study also illustrates the magnitude of leiomyoma-related hospitalizations and inpatient procedures as predicted to occur in the next 4 decades. Unless fibroid incidence decreases or outpatient, minimally invasive treatments become more accessible, effective, and used, the burden of leiomyoma-related health care will increase with the increasing population and changing demographics as we move toward 2050. These projections differentially impact black vs white women and may serve as a tangible tool to inform surgeon availability, healthcare distribution policies, and research fund allocation for the management of uterine leiomyoma.
For future direction, it will be important to look at the upcoming years’ NIS data to identify changes in the rates of inpatient leiomyoma-related care, particularly as there have been large advances and more popular acceptance of minimally invasive treatment of fibroids (eg, robotic surgery, UAE), allowing more outpatient and short-stay treatments. Such changes will hopefully reduce inpatient care of uterine leiomyoma and alter the course of the health care demands projected in this study. In addition, there is a growing body of recent literature that examines cost and compares treatment modalities using validated outcomes (eg, quality of life); such studies are providing the data that will allow a more analytical approach to leiomyoma treatment, mindful of economic and health benefits on both an individual patient and population basis. Perhaps most importantly, our projections in this study mandate a commitment to research in uterine leiomyoma, focused on cause, prevention, medical treatment, and racial disparities, as a high-yield target for dramatically improving the future of women’s health.