Treatment of Uterine Fibroid-Related Heavy Menstrual Bleeding: Variations in Clinical Practice at Four Hospitals in the Netherlands

Introduction: Uterine fibroids are the most common anatomical cause of heavy menstrual bleeding. To which extent clinical practice variation is present in the treatment of fibroid-related heavy menstrual bleeding at the hospital level remains unclear. The aim of this study was to identify and evaluate the clinical practice variation in the treatment of fibroid-related heavy menstrual bleeding. Material and methods: In this multicenter, retrospective database study, pseudonymized real-world data were collected from electronic health records using a natural language processing and text-mining data collection tool. Women <= 55 years, who presented as new patients at the gynecology outpatient clinic in 2019 with heavy menstrual bleeding and fibroids, were selected. Data were extracted from the first appointment in 2019 throughout December 2022. The primary outcome was the number of treatments initiated. Secondary outcomes were the type of treatments initiated, treatments initiated prior to hysterectomy, and time to hysterectomy. Results: From four hospitals, 623 women were included. The median age was 46 (range: 23-55) years. Overall, a median of one treatment (range: 1-4) was initiated, which significantly differed between hospitals (p < 0.01). Pharmacological treatment was initiated most frequently, which differed significantly among hospitals (392/623 [62.9%], range: 49.1%-70.5%, p = 0.02). Minimally invasive therapies were initiated in 51.2% (319/623, range: 40.6%-58.9%, p < 0.01). Only 30/319 patients (9.4%) received a minimally invasive uterus-sparing treatment. Hysterectomy was performed in 123/319 patients (38.6%), with Hospital 1 being an outlier as 52.3% underwent hysterectomy, compared to 23.9%-36.4% in the other hospitals (p < 0.01). Conclusions: Clinical practice variation is present in the treatment of heavy menstrual bleeding in Dutch women with fibroids. Organizational factors could partially explain clinical practice variation. Sharing data can aid in identifying, explaining, and acting on (un)warranted practice variation between healthcare clinics. While clinical practice variation remains inevitable, unwarranted practice variation should be limited by ameliorating guideline adherence, educational interventions, and patient counseling, to improve the quality, efficiency, and equity of care.