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Alagh A, Ramm O, Lyon LL, Ritterman Weintraub ML, Shatkin-Margolis A. Implication of Neighborhood Deprivation Index on Pelvic Organ Prolapse Management. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024:02273501-990000000-00183. [PMID: 38465980 DOI: 10.1097/spv.0000000000001501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
IMPORTANCE Differences in the rate of diagnosis of POP have been described based on race and ethnicity; however, there are few data available on the management and treatment patterns of POP based on multiple factors of socioeconomic status and deprivation. OBJECTIVE The objective of this study was to investigate the association between pelvic organ prolapse (POP) management and the Neighborhood Deprivation Index (NDI), a standardized multidimensional measure of socioeconomic status. METHODS This retrospective cohort study included female members of a large integrated health care delivery system who were 18 years or older and had ≥4 years of continuous health care membership from January 1, 2015, to December 31, 2019. Demographic, POP diagnosis, urogynecology consultation, and surgical treatment of POP were obtained from the electronic medical record. Neighborhood Deprivation Index data were extrapolated via zip code and were reported in quartiles, with higher quartiles reflecting greater deprivation. Descriptive, bivariate, and logistic regression analyses were conducted by NDI. RESULTS Of 1,087,567 patients identified, 34,890 (3.2%) had a POP diagnosis. Q1, the least deprived group, had the highest prevalence of POP (26.3%). Most patients with POP identified as White (57.3%) and represented approximately a third of Q1. Black patients had the lowest rate of POP (5.8%) and comprised almost half of Q4, the most deprived quartile. A total of 13,730 patients (39.4%) had a urogynecology consultation, with rates ranging from 23.6% to 26.4% (P < 0.01). Less than half (12.8%) of patients with POP underwent surgical treatment, and the relative frequencies of procedure types were similar across NDI quartiles except for obliterative procedures (P = 0.01). When controlling for age, no clinically significant difference was demonstrated. CONCLUSIONS Differences in urogynecology consultation, surgical treatment, and surgical procedure type performed for prolapse across NDI quartiles were not found to be clinically significant. Our findings suggest that equitable evaluation and treatment of prolapse can occur through a membership-based integrated health care system.
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Affiliation(s)
- Amy Alagh
- From the Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente Oakland, Kaiser Permanente East Bay-University of California San Francisco Urogynecology Fellowship Training Program
| | - Olga Ramm
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of California San Francisco, Kaiser Permanente East Bay-University of California San Francisco Urogynecology Fellowship Training Program
| | - Liisa L Lyon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Abigail Shatkin-Margolis
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of California San Francisco, Kaiser Permanente East Bay-University of California San Francisco Urogynecology Fellowship Training Program
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Bossick AS, Abood JA, Oaks A, Vilkins A, Shukr G, Chamseddine P, Wegienka GR. Racial disparities between measures of area deprivation and financial toxicity, and uterine volume in myomectomy patients. BMC Womens Health 2023; 23:603. [PMID: 37964227 PMCID: PMC10648622 DOI: 10.1186/s12905-023-02761-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND At time of myomectomy, a surgical procedure to remove uterine fibroids, Black women tend to have larger uteri than White women. This makes Black patients less likely to undergo a minimally invasive myomectomy which has been shown to have less postoperative pain, less frequent postoperative fever and shorter length of stay compared to abdominal myomectomies. The associations between individual financial toxicity and community area deprivation and uterine volume at the time of myomectomy have not been investigated. METHODS We conducted a secondary data analysis of patients with fibroids scheduled for myomectomy using data from a fibroid treatment registry in [location]. We used validated measures of individual-level Financial Toxicity (higher scores = better financial status) and community-level Area Deprivation (ADI, high scores = worse deprivation). To examine associations with log transformed uterine volume, we used linear regression clustered on race (Black vs. White). RESULTS Black participants had worse financial toxicity, greater deprivation and larger uterine volumes compared with White participants. A greater Financial Toxicity score (better financial status) was associated with lower uterine volume. For every 10 unit increase in Financial Toxicity, the mean total uterine volume decreased by 9.95% (Confidence Interval [CI]: -9.95%, -3.99%). ADI was also associated with uterine volume. A single unit increase in ADI (worse deprivation) was associated with a 5.13% (CI: 2.02%, 7.25%) increase in mean uterine volume. CONCLUSION Disproportionately worse Financial Toxicity and ADI among Black patients is likely due to structural racism - which now must be considered in gynecologic research and practice. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Andrew S Bossick
- Department of Public Health Sciences, Henry Ford Health, 48202, Detroit, MI, USA.
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, 965 Wilson Rd, 48224, East Lansing, MI, USA.
| | - Joelle Aoun Abood
- Department of Obstetrics and Gynecology, Henry Ford Health, 48202, Detroit, MI, USA
| | - Ashlee Oaks
- Department of Public Health Sciences, Henry Ford Health, 48202, Detroit, MI, USA
| | - Annmarie Vilkins
- Department of Obstetrics and Gynecology, Henry Ford Health, 48202, Detroit, MI, USA
| | - Ghadear Shukr
- Department of Obstetrics and Gynecology, Henry Ford Health, 48202, Detroit, MI, USA
| | - Petra Chamseddine
- Department of Obstetrics and Gynecology, Henry Ford Health, 48202, Detroit, MI, USA
| | - Ganesa R Wegienka
- Department of Public Health Sciences, Henry Ford Health, 48202, Detroit, MI, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, 965 Wilson Rd, 48224, East Lansing, MI, USA
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Wieslander CK, Grimes CL, Balk EM, Hobson DTG, Ringel NE, Sanses TVD, Singh R, Richardson ML, Lipetskaia L, Gupta A, White AB, Orejuela F, Meriwether K, Antosh DD. Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review. Obstet Gynecol 2023; 142:1044-1054. [PMID: 37826848 DOI: 10.1097/aog.0000000000005389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/30/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications. DATA SOURCES PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022. METHODS OF STUDY SELECTION The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies. TABULATION, INTEGRATION, AND RESULTS Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy. CONCLUSION Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021234511.
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Affiliation(s)
- Cecilia K Wieslander
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California; the Division of Urogynecology & Reconstructive Pelvic Surgery, Departments of Obstetrics and Gynecology and Urology, New York Medical College, Valhalla, New York; the Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, Michigan; the Division of Urogynecology & Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Howard University College of Medicine, Washington, DC; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Florida Health, Jacksonville, Florida; Occom Health, Newton, Massachusetts; the Division of Urogynecology & Reconstructive Pelvic Surgery, Cooper Health University, Cooper Medical School at Rowan University, Camden, New Jersey; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Louisville Health, Louisville, Kentucky; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Texas at Austin Dell Medical School, Austin, and the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Baylor College of Medicine, the Division of Urogynecology, Department of Obstetrics & Gynecology, Houston Methodist Hospital, Houston, Texas; and the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of New Mexico, Albuquerque, New Mexico
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Ing BI, Scott ME, Lentz SE. Opportunities Missed: Cervix Cancer Screening Failures in Women Aged 65 and Older. J Low Genit Tract Dis 2023; 27:337-342. [PMID: 37467471 DOI: 10.1097/lgt.0000000000000759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVES This study aimed to determine the screening history and associated outcomes of women diagnosed with cervical cancer after age 65. METHODS All patients from 2012 to 2021 diagnosed with squamous, adenocarcinoma, neuroendocrine, or adenosquamous cervical cancer after age 65 in a single managed care organization (MCO) were included in this retrospective cohort study. Demographic, medical, screening, pathologic, follow-up, and treatment data were extracted. Statistical analysis was done using chi-square test and logistic regression. Cancer-specific survival was estimated using the Kaplan-Meier method. RESULTS Of 2,175 patients screened, 209 met inclusion criteria. Only 26.3% of patients had appropriate cervical cancer screening and 41% of patients died of their disease. Managed care organization membership duration of more than 5 years positively correlated with proper cervical cancer screening ( p < .001); however, 64% of the long-term members still did not meet criteria to end screening at age 65, with 42.6% of these patients having more than 25 physician visit opportunities to address screening. Increased physician visits correlated with earlier stage at diagnosis of cervical cancer ( p = .012). Median cancer-specific survival was significantly better in properly screened patients at 68 vs 30 months, respectively ( p = .03). CONCLUSIONS Most patients diagnosed with cervical cancer after age 65 did not have adequate previous screening, including those who were MCO members for more than 5 years. There were many missed opportunities for screening, despite multiple provider touchpoints. The authors' data suggest that adequate screening confers a survival benefit secondary to earlier stage at diagnosis. Further study in this age group is needed to redefine the criteria to end cervix cancer screening.
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Affiliation(s)
- Brandon I Ing
- Division of Gynecologic Oncology, Southern California Permanente Medical Group, Los Angeles, CA
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Carey ET, Moore KJ, McClurg AB, Degaia A, Tyan P, Schiff L, Dieter AA. Racial Disparities in Hysterectomy Route for Benign Disease: Examining Trends and Perioperative Complications from 2007 to 2018 Using the NSQIP Database. J Minim Invasive Gynecol 2023; 30:627-634. [PMID: 37037283 DOI: 10.1016/j.jmig.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/25/2023] [Accepted: 03/29/2023] [Indexed: 04/12/2023]
Abstract
STUDY OBJECTIVE To examine national trends among race and ethnicity and route of benign hysterectomy from 2007 to 2018. DESIGN This is a retrospective analysis of the prospective National Surgical Quality Improvement Program cohort program. SETTING This study included data from the National Surgical Quality Improvement Program database including data from the 2014 to 2018 targeted hysterectomy files. PATIENTS Adult patients undergoing hysterectomy. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS: Current Procedural Terminology codes identified women undergoing benign hysterectomy and perioperative data including race and ethnicity were obtained. To determine relative trends in hysterectomy among race and ethnicity cohorts (White, Black, Hispanic), we calculated the proportion of each procedure performed annually within each race and ethnicity group and compared it across groups. From 2007 to 2018, 269 794 hysterectomies were collected (190 154 White, 45 756 Black, and 33 884 Hispanic). From 2007 to 2018, rates of laparoscopic hysterectomy increased in all cohorts (30.2%-71.6% for White, 23.9%-58.5% for Black, 19.9%-64.0% for Hispanic; ptrend <0.01 for all). For each year from 2007 to 2018, the proportion of women undergoing open abdominal hysterectomy remained twice as high in Black Women compared with White women (33.1%-14.4%, p <.01). Data from the 2014 to 2018 targeted files showed Black and Hispanic women undergoing benign hysterectomy were generally younger, had larger uteri, were more likely to be current smokers, have diabetes and/or hypertension, have higher body mass index, and have undergone previous pelvic surgery (p ≤.01 for all). CONCLUSION Compared with White women, Black and Hispanic women are less likely to undergo benign hysterectomy via a minimally invasive approach. Although larger uteri and comorbid conditions may attribute to higher rates of open abdominal hysterectomy, the higher prevalence of abdominal hysterectomy among younger Black and Hispanic women highlights potential racial disparities in women's health and access to care.
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Affiliation(s)
- Erin T Carey
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Kristin J Moore
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Asha B McClurg
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ayana Degaia
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paul Tyan
- Capital Women's Care, Ashburn, Virginia
| | - Lauren Schiff
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alexis A Dieter
- Department of Obstetrics and Gynecology , University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC
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Schneyer RJ, Greene NH, Wright KN, Truong MD, Molina AL, Tran K, Siedhoff MT. The Impact of Race and Ethnicity on Use of Minimally Invasive Surgery for Myomas. J Minim Invasive Gynecol 2022; 29:1241-1247. [PMID: 35793780 DOI: 10.1016/j.jmig.2022.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVE To determine whether minimally invasive surgery (MIS) for uterine myomas is used differentially based on race and ethnicity. DESIGN Retrospective cohort study. SETTING Quaternary care academic hospital in the United States. PATIENTS Patients undergoing hysterectomy or myomectomy for uterine myomas between March 15, 2015, and March 14, 2020 (N = 1311). Cases involving correction of pelvic organ prolapse, malignancy, peripartum hysterectomy, or combined procedures with nongynecologic specialties were excluded. Racial/ethnic composition of the study population was 40.0% non-Hispanic white (white), 27.9% non-Hispanic black (black), 14.0% Hispanic, 13.7% non-Hispanic Asian (Asian), and 4.3% non-Hispanic American Indian/Alaska Native/Pacific Islander/Other. INTERVENTIONS Hysterectomy, myomectomy. MEASUREMENTS AND MAIN RESULTS Of the 1311 cases, 35.9% were minimally invasive hysterectomy, 16.4% abdominal hysterectomy, 35.6% minimally invasive myomectomy, and 12.1% abdominal myomectomy. MIS rates were 94.7% among fellowship-trained minimally invasive gynecologic surgery subspecialists, 44.2% among obstetrics and gynecology specialists, and 46.8% among gynecologic oncologists. There were disparities in surgeon type based on race/ethnicity, with 59.8% of white patients having undergone surgery with a minimally invasive gynecologic surgery subspecialist vs 44.0% of black patients and 45.7% of Hispanic patients. Black and Hispanic patients were less likely to undergo MIS overall vs white patients (adjusted odds ratio [aOR] 0.33, 95% confidence interval [CI] 0.22-0.48 and aOR 0.44, 95% CI 0.28-0.72, respectively). Black and Hispanic patients undergoing hysterectomy were less likely than white patients to undergo MIS (aOR 0.33, 95% CI 0.21-0.51 and aOR 0.35, 95% CI 0.20-0.60, respectively). There were no significant differences in rates of MIS based on race/ethnicity for myomectomies nor differences in major or minor complications by race/ethnicity overall. CONCLUSION At a quaternary care institution, black and Hispanic patients were significantly less likely than white patients to undergo MIS for uterine myomas, particularly for hysterectomy.
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Affiliation(s)
- Rebecca J Schneyer
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Schneyer, Greene, and Molina), Los Angeles, California.
| | - Naomi H Greene
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Schneyer, Greene, and Molina), Los Angeles, California
| | - Kelly N Wright
- Division of Minimally Invasive Gynecologic Surgery, Cedars-Sinai Medical Center (Drs. Wright, Truong, and Siedhoff), Los Angeles, California
| | - Mireille D Truong
- Division of Minimally Invasive Gynecologic Surgery, Cedars-Sinai Medical Center (Drs. Wright, Truong, and Siedhoff), Los Angeles, California
| | - Andrea L Molina
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Schneyer, Greene, and Molina), Los Angeles, California
| | - Kevin Tran
- David Geffen School of Medicine at UCLA (Dr. Tran), Los Angeles, California
| | - Matthew T Siedhoff
- Division of Minimally Invasive Gynecologic Surgery, Cedars-Sinai Medical Center (Drs. Wright, Truong, and Siedhoff), Los Angeles, California
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Ajao MO. Elevating Gynecologic Surgery for All: Racial Disparities in the Use of Minimally Invasive Surgery for Myomas. J Minim Invasive Gynecol 2022; 29:1199-1200. [PMID: 36130705 DOI: 10.1016/j.jmig.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/11/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Mobolaji O Ajao
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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King LP. The Pay Gap in Gynecologic Surgery and Its Effects on Training Quality. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Louise P. King
- Brigham and Women's Hospital, Center for Bioethics Harvard Medical School, and Petrie Flom Center Harvard Law School
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Very Low Rates of Ureteral Injury in Laparoscopic Hysterectomy Performed by Fellowship-Trained Minimally Invasive Gynecologic Surgeons. J Minim Invasive Gynecol 2022; 29:1099-1103. [PMID: 35691546 DOI: 10.1016/j.jmig.2022.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/31/2022] [Accepted: 06/04/2022] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE The objective of this case series is to evaluate the rates of ureteral injury at the time of laparoscopic hysterectomy among high-volume fellowship-trained surgeons. DESIGN A retrospective chart review was performed, evaluating laparoscopic hysterectomy cases between 2009-2019 performed exclusively by fellowship-trained surgeons. SETTING Division of Minimally Invasive Gynecologic Surgery (MIGS) at the Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital, a Harvard Medical School teaching hospital in Boston. PATIENTS All patients undergoing laparoscopic hysterectomy by one of five surgeons with fellowship training in Minimally Invasive Gynecologic Surgery (MIGS). INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS: A total of 5,160 cases were performed by MIGS surgeons between 2009-2019 at our institution. Out of these cases, 2,345 were laparoscopic hysterectomy cases with available intraoperative and postoperative documentation. Most patients had prior surgeries and the most common indications for hysterectomy included uterine fibroids, pelvic pain/endometriosis, and abnormal uterine bleeding. At the time of hysterectomy, 1 ureteral injury (0.04%) was noted. No additional delayed ureteral injuries were observed. The majority of patients were discharged home the same day (64.9%) and did not have any postoperative complications (63.9%) as designated by the Clavien-Dindo classification. CONCLUSION Ureteral injury, while rare, is more prevalent in gynecologic surgery as compared to other surgical disciplines that have some focus in the pelvis. No study to date has evaluated the effect of surgical training and volume on rates of ureteral injuries. This study retrospectively examined ureteral injury rates for one group of high-volume fellowship-trained surgeons and found their rates to be lower than the national average. Proposals are presented for optimizing training and delivery of gynecologic surgical care to minimize complications.
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Zaritsky E, Le A, Tucker LY, Ojo A, Weintraub MR, Raine-Bennett T. Minimally invasive myomectomy: practice trends and differences between Black and non-Black women within a large integrated healthcare system. Am J Obstet Gynecol 2022; 226:826.e1-826.e11. [PMID: 35101407 DOI: 10.1016/j.ajog.2022.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/13/2021] [Accepted: 01/24/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Although multiple professional organizations encourage minimally invasive surgical approaches whenever feasible, nationally, fewer than half of myomectomies are performed via minimally invasive routes. Black women are less likely than their non-Black counterparts to have minimally invasive surgery. OBJECTIVE This study aimed to assess the trends in surgical approach among women who underwent minimally invasive myomectomies for uterine leiomyomas within a large integrated healthcare system as initiatives were implemented to encourage minimally invasive surgery, particularly evaluating differences in the proportion of minimally invasive surgery performed in Black vs non-Black women. STUDY DESIGN We conducted a retrospective cohort study of women, aged ≥18 years, who underwent a myomectomy for a uterine leiomyoma within Kaiser Permanente Northern California between 2009 and 2019. Generalized estimating equations and Cochran-Armitage testing were used to assess myomectomy incidence and linear trend in the proportions of myomectomy by surgical route-abdominal myomectomy and minimally invasive myomectomy. Multivariable logistic regression analyses were used to assess the associations between surgical route and (1) race and ethnicity and (2) complications, controlling for patient demographic, clinical, and surgical characteristics. RESULTS A total of 4033 adult women underwent a myomectomy during the study period. Myomectomy incidence doubled from 0.12 (95% confidence interval, 0.12-0.13) per 1000 women in 2009 to 0.25 (95% confidence interval, 0.24-0.25) per 1000 women in 2019 (P<.001). During the 11-year study period, the proportion of minimally invasive myomectomy increased from 6.0% to 89.5% (a 15-fold increase). The proportion of minimally invasive myomectomy in Black women remained lower than in non-Black women (54.5% vs 64.7%; P<.001). Black women undergoing myomectomy were younger (36.4±5.6 vs 37.4±5.8 years; P<.001), had a higher mean fibroid weight (436.0±505.0 vs 324.7±346.1 g; P<.001), and had a higher mean body mass index (30.8±7.3 vs 26.6±5.9 kg/m2; P<.001) than their non-Black counterparts. In addition to patient race, surgery performed between 2016 and 2019 compared with surgery performed between 2009 and 2012 and higher surgeon volume compared with low surgeon volume were associated with an increased proportion of minimally invasive myomectomy (adjusted relative risks, 12.58 [95% confidence interval, 9.96-15.90] and 6.63 [95% confidence interval, 5.35-8.21], respectively). Black race and fibroid weight of >500 g each independently conferred lower rates of minimally invasive myomectomy. In addition, there was an interaction between race and fibroid weight such that Black women with a fibroid weight of ≤500 g or >500 g were both less likely to have minimally invasive myomectomy than non-Black women with a fibroid weight of ≤500 g (adjusted relative risks, 0.74 [95% confidence interval, 0.58-0.95] and 0.26 [95% confidence interval, 0.18-0.36], respectively). Operative, perioperative, and medical complications were low during the 11-year study period. In regression analyses, after controlling for race, age, fibroid weight, parity, low-income residence, body mass index, surgeon volume, and year of myomectomy, the risk of complications was not markedly different comparing abdominal myomectomy with minimally invasive myomectomy. Similar results were found comparing laparoscopic minimally invasive myomectomy with robotic-assisted minimally invasive myomectomy except for women who underwent laparoscopic minimally invasive myomectomy had a lower risk of experiencing any medical complications than those who underwent robotic-assisted minimally invasive myomectomy (adjusted relative risk, 0.27; 95% confidence interval, 0.09-0.83; P=.02). CONCLUSION Within an integrated healthcare delivery system, although initiatives to encourage minimally invasive surgery were associated with a marked increase in the proportion of minimally invasive myomectomy, Black women continued to be less likely to undergo minimally invasive myomectomy than their non-Black counterparts. Race and fibroid weight alone did not explain the disparities in minimally invasive myomectomy.
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Karia PS, Huang Y, Tehranifar P, Visvanathan K, Wright JD, Genkinger JM. Racial and ethnic differences in the adoption of opportunistic salpingectomy for ovarian cancer prevention in the United States. Am J Obstet Gynecol 2022; 227:257.e1-257.e22. [PMID: 35489439 PMCID: PMC9308662 DOI: 10.1016/j.ajog.2022.04.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/03/2022] [Accepted: 04/23/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Clinicians in the United States have rapidly adopted opportunistic salpingectomy for ovarian cancer prevention. However, little is known about racial and ethnic differences in opportunistic salpingectomy adoption. Surgical innovations in gynecology may be adopted differentially across racial and ethnic groups, exacerbating current disparities in quality of care. OBJECTIVE This study aimed to evaluate racial and ethnic differences in opportunistic salpingectomy adoption across inpatient and outpatient settings and assess the effect of national guidelines supporting opportunistic salpingectomy use on these differences. STUDY DESIGN A sample of 650,905 women aged 18 to 50 years undergoing hysterectomy with ovarian conservation or surgical sterilization from 2011 to 2018 was identified using the Premier Healthcare Database, an all-payer hospital administrative database, including more than 700 hospitals across the United States. The association between race and ethnicity and opportunistic salpingectomy use was examined using multivariable-adjusted mixed-effects log-binomial regression models accounting for hospital-level clustering. Models included race and ethnicity by year of surgery (2011-2013 [before guideline] and 2014-2018 [after guideline]) interaction term to test whether racial and ethnic differences in opportunistic salpingectomy adoption changed with the release of national guidelines supporting opportunistic salpingectomy use. RESULTS From 2011 to 2018, 82,792 women underwent hysterectomy and opportunistic salpingectomy (non-Hispanic White, 60.3%; non-Hispanic Black, 18.8%; Hispanic, 12.2%; non-Hispanic other race, 8.7%) and 23,398 women underwent opportunistic salpingectomy for sterilization (non-Hispanic White, 64.7%; non-Hispanic Black, 10.8%; Hispanic, 16.7%; non-Hispanic other race, 7.8%). The proportion of hysterectomy procedures involving an opportunistic salpingectomy increased from 6.3% in 2011 to 59.7% in 2018 (9.5-fold increase), and the proportion of sterilization procedures involving an opportunistic salpingectomy increased from 0.7% in 2011 to 19.4% in 2018 (27.7-fold increase). In multivariable-adjusted models, non-Hispanic Black (risk ratio, 0.94; 95% confidence interval, 0.92-0.97), Hispanic (risk ratio, 0.98; 95% confidence interval, 0.95-1.00), and non-Hispanic other race women (risk ratio, 0.93; 95% confidence interval, 0.90-0.96) were less likely to undergo hysterectomy and opportunistic salpingectomy than non-Hispanic White women. A significant interaction between race and ethnicity and year of surgery was noted in non-Hispanic Black compared with non-Hispanic White women (P<.001), with a reduction in differences in hysterectomy and opportunistic salpingectomy use after national guideline release (risk ratio2011-2013, 0.80 [95% confidence interval, 0.73-0.88]; risk ratio2014-2018, 0.98 [95% confidence interval, 0.95-1.01]). Moreover, non-Hispanic Black women were less likely to undergo an opportunistic salpingectomy for sterilization than non-Hispanic White women (risk ratio, 0.91; 95% confidence interval, 0.88-0.95), with no difference by year of surgery (P=.62). Stratified analyses by hysterectomy route and age at surgery revealed similar results. CONCLUSION Although opportunistic salpingectomy for ovarian cancer prevention has been rapidly adopted in the United States, our findings suggested that its adoption has not been equitable across racial and ethnic groups. Non-Hispanic Black, Hispanic, and non-Hispanic other race women were less likely to undergo opportunistic salpingectomy than non-Hispanic White women even after adjusting for sociodemographic, clinical, procedural, hospital, and provider characteristics. These differences persisted after the release of national guidelines supporting opportunistic salpingectomy use. Future research should focus on understanding the reasons for these differences to inform interventions that promote equity in opportunistic salpingectomy use.
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Affiliation(s)
- Pritesh S Karia
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Yongmei Huang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Parisa Tehranifar
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
| | - Kala Visvanathan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
| | - Jeanine M Genkinger
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY.
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Wright KN, Truong M, Siedhoff MT. Residency Training in Gynecologic Surgery: Where Do We Go from Here? J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kelly N. Wright
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mireille Truong
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Matthew T. Siedhoff
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Zaritsky E, Tucker LYS, Kandahari N, Ojo A, Ritterman Weintraub M, Raine-Bennett TR. Variation in Vaginal Hysterectomy Rates in an Integrated Healthcare System. J Minim Invasive Gynecol 2021; 29:489-498. [PMID: 34808378 DOI: 10.1016/j.jmig.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/05/2021] [Accepted: 11/07/2021] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE To describe trends in minimally invasive hysterectomy (MIH) and assess patient, surgical, and provider characteristics associated with differences in vaginal versus laparoscopic rates within an integrated healthcare system. DESIGN A retrospective cohort study. SETTING Kaiser Permanente Northern California from 2008 to 2018. PATIENTS Patients who underwent MIH for benign conditions excluding uterine prolapse and incontinence surgeries. INTERVENTIONS Hysterectomies. MEASUREMENTS AND MAIN RESULTS A total of 27518 hysterectomies were performed for benign indications. Of these, the proportion of MIH increased from 29.1% (2008) to 96.7% (2018) (p <.001). The proportion of vaginal hysterectomies (VHs) of all hysterectomies did not change significantly over the study period (p = .07); however, the proportion of VH among MIH cases decreased from a high of 50.6% in 2008 to 13.2% in 2018 (p <.001). VH rates were lower in obese and morbidly obese patients (p <.001 and p = .02, respectively) and in women with uterine weights >250 g (p <.001). The differences persisted after controlling for patient demographic, clinical, and surgery characteristics. Low surgical volume was inversely associated with VH (adjusted relative risk, 7.19; 95% confidence interval, 6.62-7.81; p <.001). VH rates ranged from 11.5% to 27.8% across service areas (hospitals). Service area remained a significant predictor of VH after controlling for patient (including body mass index and uterine weight) and surgery-related characteristics. Postoperative hospital stay decreased from 33.8 ± 16.4 hours (2008) to 6.1 ± 12.2 (2018) for VH. Operative time was shorter for VH than laparoscopic hysterectomies (LHs) (1.7 vs 2.5 hours; p <.001). Overall operative/perioperative complications were low and not significantly different (VH vs LH). CONCLUSION As the proportion of MIH increased, LH became the preferred route despite similar rates of postoperative stay and intraoperative complications and shorter operative time for VH compared with LH. Service area and provider volume were independent predictors of MIH route, suggesting that training and evidence-based guidelines for route selection may help preserve VH rates.
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Affiliation(s)
- Eve Zaritsky
- Department of Obstetrics and Gynecology (Drs. Zaritsky, Ojo, and Raine-Bennett).
| | | | - Nazineen Kandahari
- Kaiser Permanente Northern California, Oakland Medical Center, Oakland, and School of Medicine, University of California, San Francisco, San Francisco(Ms. Kandahari), California
| | - Anthonia Ojo
- Department of Obstetrics and Gynecology (Drs. Zaritsky, Ojo, and Raine-Bennett)
| | | | - Tina R Raine-Bennett
- Department of Obstetrics and Gynecology (Drs. Zaritsky, Ojo, and Raine-Bennett); Division of Research (Ms. Tucker and Dr. Raine-Bennett)
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Ptacek I, Aref-Adib M, Mallick R, Odejinmi F. Each Uterus Counts: A narrative review of health disparities in benign gynaecology and minimal access surgery. Eur J Obstet Gynecol Reprod Biol 2021; 265:130-136. [PMID: 34492607 DOI: 10.1016/j.ejogrb.2021.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/11/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Health disparities exposed by the Covid-19 pandemic have prompted healthcare professionals to investigate disparities within their own specialty. Racial and ethnic disparities in obstetrics are well documented but inequities in gynaecology are less well known. Our aim is to review the literature on two commonly performed procedures, hysterectomy and myomectomy, and one condition, ectopic pregnancy, to evaluate the prevalence of racial, ethnic and socioeconomic disparities in benign gynaecology and minimal access surgery. METHODS A narrative review of 33 articles identified from a Pubmed using the following search criteria; "race"; "ethnicity"; "socioeconomic status"; "disparity"; "inequity"; and "inequality". Case reports and papers assessing gynaecological malignancy were excluded. RESULTS Despite minimal access surgery having fewer complications and faster recovery than open surgery, US studies have shown that black and ethnic minority women are less likely than white women to have minimally invasive hysterectomies and myomectomies. Uninsured women and patients on Medicaid are also less likely to receive minimally invasive procedures. Contributing factors include fibroid size, geographic location and access to hospitals performing minimal access surgery, and the discontinuation of power morcellation. Ethnic minority women who receive minimally invasive myomectomy have been shown to have a higher risk of complications and prolonged recovery. Black and ethnic minority women also have a higher risk of morbidity and mortality from ectopic pregnancy and are more likely to receive surgical than medical management. CONCLUSION Extensive study from the US has demonstrated disparities in access to minimally invasive gynaecological surgery, whereas in the UK the data is infrequent, inconsistent and incomplete. Little is known about the influence of patient preference and counselling as well as institutional bias on health equity in gynaecology. Further research is necessary to identify interventions that mitigate these disparities in access and outcomes.
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Affiliation(s)
| | | | - Rebecca Mallick
- University Hospitals Sussex NHS Foundation Trust, United Kingdom
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Double Discrimination, the Pay Gap in Gynecologic Surgery, and Its Association With Quality of Care. Obstet Gynecol 2021; 137:657-661. [PMID: 33706362 DOI: 10.1097/aog.0000000000004309] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/17/2020] [Indexed: 11/27/2022]
Abstract
In this commentary, we describe historical and other influences that drive "double discrimination" in gynecologic surgery-lower pay in the area of surgery that boasts the largest proportion of female surgeons and is focused on female patients and explore how it results in potentially lower quality care. Insurers reimburse procedures for women at a lower rate than similar procedures for men, although there is no medically justifiable reason for this disparity. The wage gap created by lower reimbursement rates disproportionately affects female surgeons, who are disproportionately represented among gynecologic surgeons. This contributes to a large wage gap in surgery for women. Finally, poor reimbursement for gynecologic surgery pushes many obstetrics and gynecology surgeons to preferentially perform obstetric services, resulting in a high prevalence of low-volume gynecologic surgeons, a metric that is closely tied to higher complication rates. Creating equity in reimbursement for gynecologic surgery is one important and ethically required step forward to gender equity in medicine for patients and surgeons.
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Gong C, Heins CA. Discovering and Reflecting on Bias: A Discussion about Challenges and Benefits of Culturally Centered Patient Care with Women Physicians of the East Bay. Perm J 2021; 24:1-5. [PMID: 33482939 DOI: 10.7812/tpp/20.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Implicit or unconscious bias is a lens through which we see our world based on our past experiences and learned stereotypes. Within health care, this lens of bias has typically had a negative impact on patient care, particularly for marginalized populations. We sat down with 3 physicians within Kaiser Permanente East Bay to learn about their personal experiences of bias in patient care. We also discuss the importance of acknowledging bias and practicing cultural humility in order to best ally with our patients. We are hopeful our conversation with these physicians will inspire more of the same, leading to improved health care for those that have suffered from bias in the past.
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Affiliation(s)
- Chelsea Gong
- Kaiser Permanente Oakland Medical Center, Oakland, CA
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