Dilatation and curettage: praxeology.

Objectives: To determine variations in the rate of inpatient and outpatient dilatation and curettage (D&C), for the treatment of early pregnancy loss, and for the diagnosis of abnormal uterine bleeding, in 17 health regions across a Canadian province.
Design: Frequency of D&C was examined in a cohort of 1.36 million women in Alberta. All inpatient and outpatient episodes in which dilatation and curettage was used for management of early pregnancy loss and for diagnosis or treatment of abnormal uterine bleeding were included. Variations in frequency among the 17 health regions were examined.
Results: Rates of D&Cs performed following miscarriage or pregnancy showed a 4-fold variation among the 17 regions, between women aged 20 to 34 years and 35 to 49 years. Consistency within the regions, when comparing both groups of women, was significant (r2 = 0.5542, p = 0.00006). The rates for D&C for abnormal uterine bleeding showed up to 5-fold variation among the 17 regions between women aged 20 to 34 years, 35 to 49 years, and 50 years or more. The Pearson correlation coefficient for association of rates for procedure codes 69.02 and 69.09 across the regions was 0.62 (p < 0.01). Percentages of procedures performed as inpatients ranged between 33.3% and 83.3% for procedure code 69.02, and between 5% and 17% for procedure code 69.09. The Pearson correlation coefficient for inpatient surgery frequency was 0.5913 (p < 0.02) across the regions. Substantial variations in the frequency of D&C were observed among health regions, and between urban and rural dwellers.
Conclusions: Substantial variations in D&C utilization were found in Alberta, rendering the need for a more detailed analysis. The extent of variation among regions is difficult to explain on grounds other than physician preference. High variation in rates of procedure codes 69.02 and 69.09 performed on an outpatient basis suggests that lower rates of inpatients could be achieved in many regions for both procedures. The higher estimated cost of D&C procedures compared to office biopsies in Alberta is a good incentive to re-examine the role of and need for performing D&Cs.