Reviewer ’s report  
 
Title: Contemporary treatment utilization among women diagnosed with symptomatic uterine  
fibroids in the United States  
 
Version: 0 Date: 29 Aug 2019  
 
Reviewer: Xavier Fritel  
 
Reviewer's report:  
 
An interesting descriptive work that can be greatly improved. Authors must improve their 
manuscript so that the results are unde rstood outside the United States. The description of 
surgeries and complications deserves to be more detailed (including codes used). There is a lack 
of data on complications depending on the surgical procedure and approach.  
 
Abstract  
For a non -US practitio ner it is unclear what mean IBM Watson Health MarketScan® 
Commercial Claims and Encounters and Medicaid Multi -State databases. What these databases 
contain and for which use? Did they include outpatient visits? I would suggest a more descriptive 
and unders tandable worldwidely denomination.  
I don't understand what is a "12 -month post -index eligibility"  
Embolization is not reported here, why?  
The off -label qualifier for medical treatments that may be active symptoms seems to me 
exaggerated [Marret. Therapeuti c management of uterine fibroid tumors: updated French 
guidelines. Eur J Obstet Gynecol Reprod Biol 2012]  
 
Data sources  
It is still unclear for me if women requiring only outpatient visits were included. How and who 
completed these databases? Is a quality p rocedure provided for in these databases to verify the 
veracity of the information collected? Is chaining planned to link the information collected in 
different places and times?  
 
Outcomes  
It unclear for me how "race" was defined  
Please explain how each outcome was defined. Did you use the CIM -10? If yes, please provide a 
list of the codes used for each outcome, complications included.  
Please explain what are the "Elixhauser category" or "Elixhauser and Deyo -Charlson co -
morbidity s ummary scores". I am not familiar with  
What is "ablation"? Is it radiofrequency or MR -HIFU?  
What was the definition used for complication? I didn't find any.  
It seems strange to me to consider embolization as a surgical procedure.  
 
 
 
 
Results  
How did the auth ors explain that no embolization was performed in the Medicaid group?  
Do I need to understand that no complication was reported after myomectomy by hysteroscopy? 
Please explain how it is possible. Please make the difference in the tables between myomectomy  
by laparotomy, by laparoscopy, and by hysteroscopy. Idem for hysterectomy by laparotomy, 
laparoscopy and by the vaginal route.  
I am afraid that I didn't understand what means "post -operative adhesions", what were the 
symptoms? How the diagnosis was perfor med? What were the other complications?  
It seems that the analysis were not only descriptive (as specified) but that some comparisons 
were performed (for example by age line 219; considering pre -index contraceptive use, line 256; 
or by symptoms, line 260),  what were the authors a priori hypotheses? Please explain and justify 
in the introduction your hypotheses and complete the comparative analysis planned in the 
method section.  
 
Discussion  
A major flaw is that we didn't know how the diagnosis of myoma was do ne and if the treatment 
was related to the myoma, isn't it?  
 
Conclusion  
I am afraid that the last sentence is not supported directly by the results. It looks more like a 
wish, could you please remove it.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is  required in your comments to the authors.  
 
No 
 
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  
organisation that may in any way gain or lose financially from the publi cation of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
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?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
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below.  If your reply is y es to any, please give details below.  
 
None  
 
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