The impact of anemia on treatment management and clinical outcomes of women hospitalized for uterine leiomyomas.

OBJECTIVES: Uterine leiomyomas are the most common benign gynecological tumors. Symptomatic leiomyomas represent a major cause of hospitalization, particularly those associated with abnormal uterine bleeding (AUB) and anemia. The aim of this study was to identify predictors of anemia in women hospitalized due to uterine leiomyomas and evaluate its impact on treatment management and clinical outcomes. MATERIAL AND METHODS: Population-based retrospective study of women hospitalized for uterine fibroids in public hospitals in mainland Portugal between 2010 and 2015. Data were extracted from the national database of the Central Administration of the Portuguese Health System. Comparative and multivariable logistic regression analysis was performed to assess outcomes. RESULTS: A total of 36 295 patients were hospitalized due to uterine leiomyomas during this period. Of those, 11.5% presented with anemia. Age, obesity, intramural type of leiomyoma and AUB are independent predictors of anemia (p < 0.001, AUC 0.7056). Anemia was associated with a high risk of inpatient hospitalization (OR: 5.161, 95% CI: 4.376-6.085), urgent admission (OR: 1.953, 95% CI: 1.797-2.121), radical surgical approach (OR: 2.559, 95% CI: 2.298-2.849), laparoscopic hysterectomy (OR: 1.575, 95% CI: 1.393-1.780) and intra- and post-operative complications (OR: 5.285, 95% CI: 4.332-6.448). It was also associated with longer hospital stays (p < 0.001). These outcomes were more pronounced in acute anemic patients. CONCLUSIONS: Anemia has a significant impact on treatment approaches and clinical outcomes of women hospitalized for uterine leiomyomas. Age, obesity, intramural leiomyomas and AUB are some predictors of anemia that could represent a risk-stratification opportunity, allowing for its prompt identification and correction, therefore improving patient care.

National trends and determinants of hospitalization for uterine leiomyomas - Portuguese public database analysis from 2000 to 2015.

OBJECTIVE: To determine the trends of hospitalization (inpatients and outpatients) for uterine leiomyomas in Portugal, over a period of fifteen years. STUDY DESIGN: We perform a population- and register-based retrospective study of women who were hospitalized with a primary diagnosis of uterine fibroid in public hospitals in continental Portugal, in the period between January 1, 2000 and December 31, 2015. Patient data regarding hospital codes, admission and discharge dates, patient age, diagnosis, procedures and complications were extracted from the national database of Administração Central do Sistema de Saúde (ACSS). All calculations were performed with the STATA software, version 13.1. Categorical data were analysed by the χ2 test and the means of continuous variables were analysed with Student's t-test. Statistical significance was set at p < 0.05. RESULTS: Between 2000 and 2015, 102 476 patients were admitted to public hospitals in Portugal due to uterine leiomyomas. The majority were admitted to hospital for surgery: 73.6 % for hysterectomy and 13.0 % for myomectomy. During this period, the definitive treatment (hysterectomy) decreased from 83.2% to 63.0% (p < 0.001), with a change towards more conservative treatments such as myomectomies (6.4% to 22.6%, p < 0.001). Additionally, in women submitted to hysterectomy, laparoscopic and vaginal routes increased (1.1%-11.5%, p < 0.001 and 2.1%-4.0%, p < 0.001; respectively). Globally, there was a 14.3 % reduction in hospitalizations due to uterine fibroids and an increase in the outpatient rate (from 3.1% to 22.1%). The mean number of hospitalization days for inpatients also decreased (from 6.3 ± 4.1-4.0 ± 3.0, p < 0.001). Regarding urgently hospitalized women, 11.8 % required a blood transfusion. In women submitted to surgical procedures, 0.5 % had an intraoperative complication and 2.3 % a post-operative complication, directly related to the surgical procedure. CONCLUSION: There was a reduction in hospitalizations due to uterine fibroids and a change towards more conservative treatments.

Hysterectomies in Portugal (2000-2014): What has changed?

OBJECTIVE: To describe conditions regarding hysterectomies during the past 15 years in Portugal. STUDY DESIGN: Nationwide retrospective study of women who underwent hysterectomy in Portuguese public hospitals in the period between 2000 and 2014. Patient data regarding hospital codes, geography, patient age, indications, operative techniques, associated procedures, complications, admission dates, discharge dates and 30-day postoperative readmissions were extracted from the national database with information regarding all public hospitals in Portugal. For calculation of hysterectomy rates, the total number of women was found using the Statistics Portugal website. Data were analysed using STATA version 13.1. RESULTS: A total of 166 177 hysterectomies were performed between 2000 and 2014 in public hospitals in Portugal. The overall rate of hysterectomy decreased 19.3% (from 212/100 000 to 171/100 000 women per year). The average age of women at time of hysterectomy increased from 51.6±11.4 to 55.2±12.3years (p<0.001). There was an increase in laparoscopic [1.2%-9.5%, p<0.001] and vaginal route [13.3%-21.2%, p<0.001], with a consequent decrease in laparotomic route [85.5%-69.1%, p<0.001]. There was a change in the pattern of indications for hysterectomy; however, uterine fibroids remain the major indication for hysterectomy [45.3%-37.6%, p<0.001]. In women with hysterectomy for benign pathology, the rate of bilateral adnexectomy decreased from 71.0% to 51.9% (p<0.001) and the rate of bilateral salpingectomy increased from 1.0% to 15.1% (p<0.001). The mean number of hospitalization days decreased from 7.1±6.1 (in 2000-2004) to 5.4±5.0 (in 2010-2014) (p<0.001). Globally, the rate of complications increased from 3.3% in 2000-2004 to 3.6% in 2010-2014 (p<0.01). CONCLUSION: In Portugal, the rate of hysterectomies decreased in the last 15 years with an increase in age at the time of the procedure and a change towards less invasive routes. Uterine fibroids remain the major indication for hysterectomy. Additionally, we noted a significant shift towards more concomitant bilateral salpingectomy (and less bilateral adnexectomy) during hysterectomy for benign indications, according to the evidence suggesting the fallopian tube as the origin of ovarian cancer.

Lowered national cesarean section rates after a concerted action.

OBJECTIVE: To evaluate national cesarean section (CS) rates and other obstetric indicators after a concerted action to reduce CS rates was undertaken in Portugal from 2010 onwards. This action was based on the transmission of information and training of healthcare professionals, together with the inclusion of CS rates as a criterion for hospital funding. DESIGN: Retrospective observational population-based study. SETTING: Portugal. POPULATION: Births occurring in Portugal between 2000 and 2014. METHODS: Governmental sources were used to obtain data on national CS, perinatal and maternal mortality rates. Rates of instrumental vaginal delivery, vaginal birth after cesarean (VBAC), hypoxia-related complications and perineal lacerations were retrieved for state-owned hospitals. MAIN OUTCOME MEASURES: CS, perinatal and maternal mortality, instrumental vaginal delivery, VBAC, hypoxia-related complications and perineal lacerations. RESULTS: After a continuous rise between 2000 and 2009, national CS rates declined significantly over the following 5 years (36.6% vs. 33.1%, time trend p ≤ 0.001). Perinatal mortality maintained a downward trend during this period, while maternal mortality remained unchanged. Rates of instrumental vaginal delivery, VBAC and perineal lacerations increased, while the incidence of hypoxia-related complications decreased. CONCLUSIONS: A concerted action based on the transmission of information and training of healthcare professionals, together with the inclusion of CS rates as a criterion for hospital funding, was followed by a significant reduction in national CS rates, as well as an improvement in most related obstetric indicators. There may be an association between the reported intervention and the observed changes.