Objective
To estimate leiomyoma-related inpatient care in the United States for 2007 with predictions for the ensuing 40 years.
Study Design
We used the 2007 Nationwide Inpatient Sample to estimate hospitalizations and inpatient surgeries for uterine leiomyoma in US women 15 to 54 years. We used the US Census Bureau population projections to predict leiomyoma-related inpatient care through 2050.
Results
In 2007, 355,135 women were hospitalized for leiomyoma (rate = 42 per 10,000 women-years). Black women had increased rates of hospitalization, hysterectomy, and myomectomy (relative risk, 3.5, 2.4, 6.8, respectively) compared with white women. Leiomyoma-related hospitalizations are predicted to increase 23% (to 437,874) between 2007 and 2050, with 20% and 31% increases in leiomyoma-related hysterectomies and myomectomies.
Conclusion
Leiomyoma-related inpatient care and major surgery remains substantial despite advances in less invasive treatment options. Given population growth, the projected burden of leiomyoma-related inpatient care will increase significantly by 2050, differentially impacting black vs white women.
Uterine leiomyoma, (fibroids) and their treatment are arguably the most significant women’s health issue facing reproductive-aged women in the United States today. Leiomyoma are the most common reproductive tumor in women. By age 50, cumulative incidence of ultrasound-detected fibroids for white women is almost 70% and more than 80% for black women; moreover, for women in their thirties and forties with ultrasound-detected leiomyoma, up to 35% of white and 50% of black women will have symptoms. Leiomyoma-related symptoms are associated with a dramatically decreased quality of life and health. Common symptoms from leiomyoma are heavy, painful menstrual bleeding, often leading to anemia, and “bulk” symptoms such as pelvic pressure and urinary frequency. Women with leiomyoma are more likely to miss work and to experience certain pregnancy complications.
Women with leiomyoma incur total health care costs over twice that of their counterparts without leiomyoma and the majority of costs come from inpatient care. Absenteeism and disability from fibroids results in indirect costs equivalent to direct healthcare costs. Though not all women seek treatment for their symptoms, leiomyoma are the primary indication for hysterectomy in this country, accounting for 33% to more than 40% of the approximately 600,000 hysterectomies each year. Hysterectomy for leiomyoma exceeds the number of hysterectomies performed for all types of gynecologic cancers combined. Minimally invasive treatments, such as uterine artery embolization (UAE) and magnetic resonance guided focused ultrasound surgery (MRgFUS), are available but underused, and most leiomyoma treatment still involves an inpatient hospital stay with its associated disadvantages, including cost.
Age and race are the 2 major determinants of fibroid burden. Premenopausal women, generally between ages 35 and 45, are the most affected group. Although white, Asian, and Hispanic women are currently thought to have similar incidence of leiomyoma, black women bear a disproportionate burden from fibroids.
As a pressing women’s health issue, uterine leiomyoma and their treatment patterns demand informed planning as we navigate the current health care environment. Our first objective in this study was to update the data describing current leiomyoma-related hospitalizations and surgery. To reflect the growing US population and projected racial distribution changes, we also created predicted scenarios for the coming decades. These predictions are illustrations of the future public health burden of fibroid care, intended to guide researchers, policymakers, and healthcare agencies. These predictions will also equip training programs to calculate the number of graduates needed to meet the demands for well-trained gynecologic surgeons and women’s health care providers.
Materials and Methods
Data source
We used the 2007 data from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) to calculate the number of hospitalization, hysterectomy, and myomectomy for US women aged 15 to 54 with a diagnosis of uterine leiomyoma. The NIS is the largest US inpatient database, containing information on 7 million hospital discharges from 800 to 1000 hospitals, representing all payers. The data (patient characteristics, diagnoses, surgeries) approximate a 20% stratified sample of US community hospitals and is retained for all discharges for each hospital for the year, capturing all hospital stays with an inpatient designation. Women with uterine leiomyoma as any of their hospital diagnoses, based on the International Classification of Diseases, 9th revision , (ICD-9) Clinical Modification ( codes 218.0, 218.1, 218.2, 218.9), were included. Procedures were identified using ICD-9 procedure codes: for hysterectomy (68.3-68.9) and for myomectomy (68.29 and 68.19). Reporting of data on race is not required in the NIS and varies by state and hospital. However, given the importance of race in the study of fibroids, we examined and analyzed available race data for black and white women.
Analysis
We calculated the 2007 age-specific rates of leiomyoma-related hospitalization, hysterectomy, and myomectomy (events) for women aged 15-54 using the US Census Bureau 2007 population data. These rates were estimated individually for each 5-year age group regardless of race and then stratified for race. For example, to calculate an age and race-specific rate, we took the NIS data for the number of leiomyoma-related hospitalizations in white women, aged 40-44, and divided it by the total number of white women, aged 40-44, in the United States in 2007 as reported by the US Census. We multiplied these rates by the US Census Bureau population projections for 2010 to 2050 for each 5-year age group individually, then summed these numbers to report results by the decade (2010, 2020). These values yield age and race-specific predictions for the magnitude of future leiomyoma-related inpatient care. We used the middle series of the US Census Bureau population projections for each year and applied the 95% CI around the 2007 rates to calculate a range of leiomyoma-related events predicted for each decade.
Given the complex sampling design of the NIS, we used STATA 9.2 (StataCorp, College Station, TX) to account for sampling weights, strata, and clusters and to provide national estimates. Rate calculations and projections were performed using Microsoft Excel (Microsoft, Redmond, WA). The NIS contains only deidentified data and thus, this study was granted exemption status by the Mayo Clinic Institutional Review Board (Jacksonville, FL).
Results
In 2007, there were 355,137 leiomyoma-related hospitalizations in women aged 15-54 for a rate of 42 per 10,000 women-years (95% confidence interval [CI], 39–46). There were 538,719 hysterectomies, of which 43% had a diagnosis of leiomyoma. Although nearly one-third (101,616) of women in the NIS had missing race data, 77,001 black women and 120,688 white women allowed us to examine racial differences in this subset. For black women, the calculated rate of hospitalization was 3.5 times that in white women. For all races, combined, leiomyoma-related hysterectomy was 27 per 10,000 women-years (95% CI, 25–30), and 2.4 times more common in black women than in white women. Myomectomy rate was 4.4 per 10,000 women-years (95% CI, 3.7–5.2). According to available data, black women had 6.8 times the rate f myomectomy compared with white women ( Table 1 ).
| Event | All races | Black | White |
|---|---|---|---|
| Hospitalization | |||
| Rate | 42 | 65 | 18 |
| 95% CI | 39–46 | 54–75 | 16–20 |
| Hysterectomy | |||
| Rate | 27 | 33 | 14 |
| 95% CI | 25–30 | 28–38 | 12–15 |
| Myomectomy | |||
| Rate | 4.4 | 9.2 | 1.3 |
| 95% CI | 3.7–5.2 | 6.9–11 | 1.0–1.6 |
Assuming stable rates of these leiomyoma-related events, compared 2007 data, the number of hospitalizations should increase 23% (to 437,873) by 2050 because of an increase in the female US population and changing demographics. The number of leiomyoma-related inpatient hysterectomies is predicted to increase by 20%, with an increase of 22% in black women and 8% in white women as compared with 2007 numbers. Inpatient myomectomies are predicted to increase in number by 31%, to nearly 50,000, in 2050, with a 26% increase in black women and a 21% increase in white women compared with these figures in 2007 ( Figure and Table 2 ).
| Event | 2010 | 2020 | 2030 | 2040 | 2050 |
|---|---|---|---|---|---|
| Hospitalization | |||||
| Number of women | 351,554 | 350,943 | 380,203 | 406,318 | 437,874 |
| 95% CI | (322,354–380,754) | (321,474–380,412) | (348,368–412,037) | (372,279–440,355) | (401,123–474,624) |
| Hysterectomy | |||||
| Number of women | 228,939 | 222,800 | 243,127 | 259,485 | 278,419 |
| 95% CI | (211,288–194,199) | (205,578–181,747) | (224,353–194,452) | (239,438–204,284) | (256,904–216,981) |
| Myomectomy | |||||
| Number of women | 37,134 | 39,461 | 42,211 | 45,032 | 49,154 |
| 95% CI | (30,751–43,515) | (32,675–46,246) | (34,951–49,471) | (37,289–52,774) | (40,700–57,607) |
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