‘Persistent’ low utilization of key interventional service raises radiologist concern

Radiologists are voicing concern about the “persistent, marked” low utilization of a key interventional service in some geographies. 

Their worries stem from the delivery of uterine artery embolization for the treatment of symptomatic fibroids. This minimally invasive procedure stops blood flow to the uterus to treat UAE, relieving symptoms such as heavy menstrual bleeding, pain and pressure on the bladder. 

Embolization is a save, cost-effective alternative to a hysterectomy. However, rural hospitals account for the delivery of only about 1.2% of these interventional procedures, according to new research published Friday in the Journal of Vascular and Interventional Radiology [1]. That’s despite 12.9% of the U.S. population living in such geographies. 

“This observation is one that is not unique to UAE or interventional radiology and is a social determinant of health that may actually be worsening across the field of medicine,” Matthew A. Patetta, MD, with the Department of Radiology at the University of North Carolina School of Medicine, and co-authors wrote Nov. 22. “One potential explanation for this observation is that patients may transport themselves to larger urban centers to undergo procedural interventions. With this in mind, intentional investment must be made into rural communities to limit socioeconomic barriers such as transportation and avoid further healthcare disparities related to access, quality of care, and outcomes for UAE.”

For the study, experts at the Chapel Hill, North Carolina, institution used databases developed for the Healthcare Cost and Utilization Project spanning 2011 to 2020. Their goal was to better understand disparities in the delivery of uterine artery embolization. They found that UAE has been delivered in a “relatively equitable” fashion based on income, with improved utilization within the Medicaid population and across most geographies. Black women accounted for nearly 46% of utilization during the study period. That’s compared to 28% for white women, 14% among Latinas and 6% for Asians.

The lowest income quartile experienced no change in utilization (28%) while the highest saw a gradual decrease over a decade, falling from 27% to 19% by 2020. 

“While there is no data available to help explain this specific trend, a speculative explanation would be that this demographic may have shifted their UAE from an inpatient setting to an outpatient setting,” the authors noted. 

The Northeast region of the U.S. (49% in 2011) was replaced by the South (35% in 2020) as the geography with the highest utilization of inpatient UAE. The main insurance statuses for embolization patients were nearly 56% private payer, 26% Medicaid and 9% Medicare. Over the last decade, Medicaid has seen a gradual increase in UAE share, from 18% in 2011 up to nearly 29% by the end of the study period. 

“Medicaid patients have been shown to represent a disproportionately high amount of inpatient UAE, offset by a lower number of private insurance patients,” the authors noted. “Moreover, the observed trends of both groups across the decade appear to be exacerbating this divide. The Medicare population experienced a lower-than-expected utilization of UAE, likely attributed to this demographic primarily being composed of post-menopausal patients who would have limited benefits from a UAE for the treatment of symptomatic fibroids. Of note, it is important to highlight that the implementation of the Affordable Care Act and the expansion of Medicaid coverage/reimbursement of fibroid care may have played a role in the observed increased utilization of the Medicaid cohort.” 

Urban teaching hospitals accounted for the highest UAE total at 82% versus 16% in urban nonteaching institutions and 1% in rural hospitals. Patetta and co-authors noted “persistent high utilization” of hysterectomy at 78% of total interventions. There are multiple factors driving this figure, but one potential reason could be lack of shared decision-making. About 58% of patients cite a provider recommendation as the primary driver for undergoing a hysterectomy to address fibroids, according to previous research. 

Read more, including potential study limitations, at the link below.