{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T20:48:15Z","timestamp":1787863695906,"version":"build-2784847793"},"reference-count":30,"publisher":"Wiley","issue":"7","license":[{"start":{"date-parts":[[2024,4,17]],"date-time":"2024-04-17T00:00:00Z","timestamp":1713312000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["obgyn.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Acta Obstet Gynecol Scand"],"published-print":{"date-parts":[[2024,7]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Introduction<\/jats:title><jats:p>Many women experience bleeding disorders that may have an anatomical or unexplained origin. Although hysterectomy is the most definitive and common treatment, it is highly invasive and resource\u2010intensive. Less invasive therapies are therefore advised before hysterectomy for women with fibroids or bleeding disorders. This study has two aims related to treating bleeding disorders and uterine fibroids in the Netherlands: (1) to evaluate the regional variations in prevalence and surgical approaches; and (2) to assess the associations between regional rates of hysterectomies and less invasive surgical techniques to analyze whether hysterectomy can be replaced in routine practice.<\/jats:p><\/jats:sec><jats:sec><jats:title>Material and methods<\/jats:title><jats:p>We completed a register\u2010based study of claims data for bleeding disorders and fibroids in women between 2016 and 2020 using data from Statistics Netherlands for case\u2010mix adjustment. Crude and case\u2010mix adjusted regional hysterectomy rates were examined overall and by surgical approach. Coefficients of variation were used to measure regional variation and regression analyses were used to evaluate the association between hysterectomy and less invasive procedure rates across regions.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Overall, 14\u2009186 and 8821 hysterectomies were performed for bleeding disorders and fibroids, respectively. Laparoscopic approaches predominated (bleeding disorders 65%, fibroids 49%), followed by vaginal (bleeding disorders 24%, fibroids 5%) and abdominal (bleeding disorders 11%, fibroids 46%) approaches. Substantial regional differences were noted in both hysterectomy rates and the surgical approaches. For bleeding disorders, regional hysterectomy rates were positively associated with endometrial ablation rates (<jats:italic>\u03b2<\/jats:italic>\u2009=\u20090.11; <jats:italic>P<\/jats:italic>\u2009=\u20090.21) and therapeutic hysteroscopy rates (<jats:italic>\u03b2<\/jats:italic>\u2009=\u20090.14; <jats:italic>P<\/jats:italic>\u2009=\u20090.31). For fibroids, regional hysterectomy rates were positively associated with therapeutic hysteroscopy rates (<jats:italic>\u03b2<\/jats:italic>\u2009=\u20090.10; <jats:italic>P<\/jats:italic>\u2009=\u20090.34) and negatively associated with both embolization rates (<jats:italic>\u03b2<\/jats:italic>\u2009=\u2009\u22120.08; <jats:italic>P<\/jats:italic>\u2009=\u20090.08) and myomectomy rates (<jats:italic>\u03b2<\/jats:italic>\u2009=\u2009\u22120.03; <jats:italic>P<\/jats:italic>\u2009=\u20090.82).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Regional variation exists in the rates of hysterectomy and minimally invasive techniques. The absence of a significant substitution effect provides no clear evidence that minimally invasive techniques have replaced hysterectomy in clinical practice. However, although the result was not significant, embolization could be an exception based on its stronger negative association.<\/jats:p><\/jats:sec>","DOI":"10.1111\/aogs.14844","type":"journal-article","created":{"date-parts":[[2024,4,17]],"date-time":"2024-04-17T10:49:06Z","timestamp":1713350946000},"page":"1292-1301","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Regional practice variation in hysterectomy and the implementation of less invasive surgical procedures: A register\u2010based study in the Netherlands"],"prefix":"10.1111","volume":"103","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2099-5987","authenticated-orcid":false,"given":"Maarten D. H.","family":"Vink","sequence":"first","affiliation":[{"name":"Department of Health Economics, School of Business and Economics &amp; Talma Institute Vrije Universiteit  Amsterdam the Netherlands"},{"name":"Department of Obstetrics and Gynecology Meander Medical Center  Amersfoort the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"France R. M.","family":"Portrait","sequence":"additional","affiliation":[{"name":"Department of Health Economics, School of Business and Economics &amp; Talma Institute Vrije Universiteit  Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wouter J. K.","family":"Hehenkamp","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology Amsterdam University Medical Centers, location VUmc  Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tim","family":"van Wezep","sequence":"additional","affiliation":[{"name":"Vektis  Zeist the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xander","family":"Koolman","sequence":"additional","affiliation":[{"name":"Department of Health Economics, School of Business and Economics &amp; Talma Institute Vrije Universiteit  Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marlies Y.","family":"Bongers","sequence":"additional","affiliation":[{"name":"Grow School of Oncology and Developmental Biology Maastricht University Medical Center  Maastricht the Netherlands"},{"name":"Department of Obstetrics and Gynecology Maxima Medical Center  Velthoven the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric J. E.","family":"van der Hijden","sequence":"additional","affiliation":[{"name":"Department of Health Economics, School of Business and Economics &amp; Talma Institute Vrije Universiteit  Amsterdam the Netherlands"},{"name":"Zilveren Kruis Health Insurance  Leusden the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2024,4,17]]},"reference":[{"key":"e_1_2_12_2_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-0528.2009.02284.x"},{"key":"e_1_2_12_3_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-0528.2002.01282.x"},{"key":"e_1_2_12_4_1","doi-asserted-by":"publisher","DOI":"10.1007\/978-3-319-22497-8_1"},{"key":"e_1_2_12_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejogrb.2010.02.012"},{"key":"e_1_2_12_6_1","doi-asserted-by":"publisher","DOI":"10.3390\/jcm9123959"},{"key":"e_1_2_12_7_1","unstructured":"The American College of Obstetricians and Gynecologists.Choosing the route of hysterectomy for benign disease.2019."},{"key":"e_1_2_12_8_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12905-021-01386-2"},{"key":"e_1_2_12_9_1","doi-asserted-by":"publisher","DOI":"10.1111\/aogs.14159"},{"issue":"519","key":"e_1_2_12_10_1","first-page":"e1","article-title":"Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2\u2009years' outcome from the randomized EMMY trial","volume":"196","author":"Volkers N","year":"2007","journal-title":"Am J Obstet Gynecol"},{"key":"e_1_2_12_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2016.06.051"},{"issue":"1","key":"e_1_2_12_12_1","article-title":"Endometrial resection and ablation techniques for heavy menstrual bleeding (review)","volume":"1","author":"Bofill Rodriguez M","year":"2019","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_2_12_13_1","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.74.4.327"},{"key":"e_1_2_12_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.healthpol.2013.08.002"},{"key":"e_1_2_12_15_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvir.2008.03.001"},{"key":"e_1_2_12_16_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-0528.2006.00962.x"},{"key":"e_1_2_12_17_1","doi-asserted-by":"publisher","DOI":"10.3389\/fonc.2016.00089"},{"key":"e_1_2_12_18_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0233082"},{"key":"e_1_2_12_19_1","doi-asserted-by":"publisher","DOI":"10.1111\/jog.14517"},{"key":"e_1_2_12_20_1","unstructured":"Zelfstandige Klinieken Nederland.ZKN in kengetallen 2023 [Independent Clinics Netherlands. ZKN in key figures\u00a02023].https:\/\/www.zkn.nl\/over\u2010zkn\/kengetallen"},{"key":"e_1_2_12_21_1","unstructured":"Zorgverzekeraars Nederland.About ZN 2023 [Health insurers in the Netherlands. About ZN 2023].https:\/\/www.zn.nl\/about\u2010zn"},{"key":"e_1_2_12_22_1","unstructured":"Federatie Medisch Specialisten.Hevig Menstrueel Bloedverlies (HMB) 2023 [Federation of Medical Specialists. Heavy Menstrual Bleeding (HMB) 2023].https:\/\/richtlijnendatabase.nl\/richtlijn\/hevig_menstrueel_bloedverlies\/startpagina_\u2010_hevig_menstrueel_bloedverlies_hmb.html"},{"key":"e_1_2_12_23_1","unstructured":"Zorgauthoriteit Nederland.Open data van de Nederlandse Zorgautoriteit [Healthcare Authority of the Netherlands. 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