Reviewer ’s report  
 
Title: Contemporary treatment utilization among women diagnosed with symptomatic uterine  
fibroids in the United States  
 
Version: 1 Date: 01 Dec 2019  
 
Reviewer: Jeremy Jon athan Owen Herod  
 
Reviewer's report:  
 
Thank you for sending this paper back to me: I have reviewed the authors responses to my 
previous comments and to that of Reviewer 2. I still have  some areas that are of concern to me. 
The most important of these is my concerns about the mortality statistics.  
 
1) Lines 323 - 329. The authors state:  
 
In this study, mortality  324 rates reported for the specific type of hysterectomy - abdominal 
hyster ectomy - were 0.29%  325 (Commercial) and 1.17% (Medicaid) during the 12 -month post -
index period. While such  326 rates may seem high, it should be noted that symptomatic UF is 
not a benign disease but is  327 associated with poor quality of life, bulk sympto ms, the need for 
invasive treatments, and  328 increased healthcare resource utilization and healthcare costs, all of 
which contribute to  329 mortality rates.  
 
I would have to again disagree with this statement. I am also surprised that the authors should 
dismiss this VERY HIGH mortality rate in this manner. I accept that fibroids cause symptoms 
but they are a BENIGN condition (as in NOT cancer) and the factors l isted to be associated with 
them (QOL; bulk symptoms; inc healthcare resource utilization and costs) should not and do not 
have any impact on mortality. I have been practicing gynaecology for more than 25 years. I have 
had a very busy surgical practice whe re I have performed approx. 200 hysterectomy cases per 
annum, many of which have been complex oncology procedures. By and large a hysterectomy 
for a fibroid uterus is a straightforward and easy hysterectomy. As I have performed in excess of 
5000 hysterecto mies a death rate of 1% would mean I would have  had at least 50 deaths (ie 4 
per annum!!!)over my career and that is simply not the case and nor should it be. If I did have 
that kind of mortality rate then there is no way I would still be allowed to opera te. 
 
A death rate of &gt; 1% is a very significant finding in this study. It should really worry the 
authors. It is far higher than it should be and far higher than is reasonable for treating what is a 
benign condition. Are patients being warned pre -operati vely that they have a 1 in 100 chance of 
death????? This finding cannot simply be dismissed in the way that it is in lines 323 -329. Indeed 
my view is that the authors should be duty bound to raise this findings with the organisations 
concerned for further investigation  
 
 
Lines 355 - 358 . The use of the term IUD is misleading since a standard IUD would in all 
likelihood make matters worse. We are really referring to the levonorgestrol -releasing 
intrauterine system (aka Mirena) so the authors should be more specific.  
 
Line 369 and following. There is a comment regarding differences between populations where it 
is noted that:  
 
Commercial databases, in terms of demographics and symptomatology. For instance, 57.1%  of 
patients in the Commercial 370 population ha d a HMO insurance plan, whereas 57.9% of  371 
patients in the Medicaid population had a PPO insurance plan.  
 
Surely 57.1 and 57.9 are almost the same?  Or is it that these insurance plans are very different in 
what they offer?  Readers from outside the US m ay not understand any differences that exist.  
 
 
Are the methods appropriate and well described?  
If not, please specify what is  required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, p lease explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require furth er 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
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3. Do you hold or are you curr ently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
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