Examining Disparities in Route of Surgery and Postoperative Complications in Black Race and Hysterectomy

Risk factor evaluation and performance improvement for surgical site infections in patients undergoing abdominal hysterectomy at a large academic safety net hospital

OBJECTIVE

To identify Surgical Site Infection (SSI) risk factors for abdominal hysterectomy patients and report the results of a performance improvement initiative.

DESIGN

Retrospective case-control.

SETTING

Parkland Hospital, an 882-bed academic, safety-net, tertiary referral center and a level 1 trauma center serving a diverse population of primarily uninsured patients in North Texas.

PARTICIPANTS

Patients over 18 who underwent abdominal hysterectomy and were diagnosed with SSIs within 30 days of surgery between 2019 and 2021.

METHODS

Cases were matched to controls from the same or closest calendar month in a 1:2 ratio. Chart review of electronic medical records (EMR) was performed comparing variables using Pearson's χ2 test for categorical variables and Student's t-test for continuous variables followed by logistic regression for multivariate analysis. Upon identifying vaginal preparation technique as an area of improvement while investigating SSI bundle compliance, we implemented an OR staff training intervention.

RESULTS

Diabetes was identified as a significant risk factor while Hispanic or Latino ethnicity was associated with significantly lower rates of infection. Most organisms identified were enteric pathogens. Following the intervention, Parkland's deep and organ-space Standardized Infection Ratio (SIR) decreased from 1.46 in 2021 to 0.519 for the rolling 12 months as of June 2024.

CONCLUSIONS

Our multidisciplinary intervention improving the quality and consistency of pre-operative vaginal preparation was associated with a reduction in abdominal hysterectomy SSI.

Language-Based Disparities in Route of Hysterectomy for Benign Disease

STUDY OBJECTIVE

To assess the association between patient primary language and route of hysterectomy.

DESIGN

A retrospective cohort study was conducted using the Healthcare Cost and Utilization Project's State Inpatient Database (SID) and State Ambulatory Surgery and Services Database (SASD).

SETTING

All inpatient and outpatient hysterectomies from the most recent year of available data (2020-2021) from the six states that record patient primary language in the SID and SASD (Indiana, Iowa, Maryland, Michigan, Minnesota, and New Jersey) were queried.

PATIENTS OR PARTICIPANTS

Patients aged 18 and over undergoing an inpatient or ambulatory hysterectomy for benign indication.

INTERVENTIONS

Minimally invasive hysterectomy compared to abdominal hysterectomy.

MEASUREMENT AND MAIN RESULTS

The association between patient primary language (English vs. non-English) and route of hysterectomy (abdominal vs minimally invasive) was evaluated. The cohort included 52,226 patients who met inclusion criteria. The majority of patients were non-Hispanic White (71%), with a median age of 46 years (IQR 40.0-53.0). 91.4% of patients spoke English as their primary language, 3.6% spoke Spanish, and 5.0% spoke another non-English language. Patients with a non-English primary language were significantly less likely to undergo minimally invasive hysterectomy compared to patients who spoke English (OR 0.60, 95% CI 0.56-0.64, p <.001). This association remained significant following adjustments for age, race, insurance, median income, state, and fibroid, abnormal uterine bleeding, prolapse or endometriosis diagnosis (aOR 0.77, 95% CI 0.71-0.84). In a sensitivity analysis of English vs Spanish vs other non-English language, the association remained significant for other non-English languages (aOR 0.67, 95% CI 0.60-0.75) but not for Spanish (aOR 0.95, 95% CI 0.83-1.09).

CONCLUSION

Patients who are non-English speaking are significantly less likely to receive a minimally invasive hysterectomy. Addressing language disparities may improve access to a minimally invasive route of surgery, a possible surrogate for improved surgical outcomes, for our gynecologic patients.

Hysterectomy and medical financial hardship among U.S. women

OBJECTIVE

Hysterectomy is one of the common surgical procedures for women in the United States. Studies show that hysterectomy is associated with elevated risk of developing chronic conditions, whichmay cause financial toxicity in patients. This study aimed to assess whether women who underwent hysterectomy had a higher risk of experiencing medical financial hardship compared to women who didn't.

METHODS

Using data on 32,823 adult women from the 2019 and 2021 waves of the National Health Interview Survey, we estimated binomial and multinomial logistic regressions to assess the relationship between hysterectomy and financial hardship, defined as problems paying or unable to pay any medical bills. Further, we performed a Karlson-Holm-Breen (KHB) decomposition to examine whether the association could be explained by chronic comorbidity.

RESULTS

While the prevalence of financial hardship was 13.6 % among all women, it was 16.2 % among women who underwent a hysterectomy. The adjusted odds of experiencing medical financial hardship among women with a hysterectomy were 1.36 (95 % CI: 1.22-1.52) times that of their counterparts who did not have a hysterectomy. The KHB decomposition suggested that 34.5 % of the size of the effect was attributable to chronic conditions. Women who had a hysterectomy were also 1.45 (95 % CI: 1.26-1.67) times more likely to have unpaid medical debts.

CONCLUSIONS

Our results suggested that women, who underwent a hysterectomy in the US, were vulnerable to medical financial hardship. Policy makers and health professionals should be made aware of this issue to help women coping against this adversity.

High-Volume Surgeons and Reducing Racial Disparities in Route of Hysterectomy

STUDY OBJECTIVE

To examine racial disparities in route of hysterectomy and perioperative outcomes before and after expansion of high-volume minimally invasive surgeons (>10 minimally invasive hysterectomies [MIHs]/year).

DESIGN

Retrospective cohort study.

SETTING

Multicenter academic teaching institution.

PATIENTS

All patients who underwent a scheduled hysterectomy for benign indications during 2018 (preintervention) and 2022 (postintervention).

INTERVENTIONS

Recruitment of fellowship in minimally invasive gynecologic surgery-trained faculty and increased surgical training for academic specialists in obstetrics and gynecology occurred in 2020.

MEASUREMENTS AND MAIN RESULTS

Patients in the preintervention cohort (n = 171) were older (median age, 45 years vs 43 years; p = .003) whereas patients in the postintervention cohort (n = 234) had a higher burden of comorbidities (26% American Society of Anesthesiologists class III vs 19%; p = .03). Uterine weight was not significantly different between cohorts (p = .328). Between the pre- and postintervention cohorts, high-volume minimally invasive surgeons increased from 27% (n = 4) to 44% (n = 7) of those performing hysterectomies within the division and percentage of hysterectomies performed via minimally invasive route increased (63% vs 82%; p <.001). In the preintervention cohort, Black patients had a lower percentage of hysterectomies performed via minimally invasive route than White patients (Black = 56% MIH vs White = 76% MIH; p = .014). In the postintervention cohort, differences by race were no longer significant (Black = 78% MIH vs White = 87% MIH; p = .127). There was a significant increase (22%) in MIH for Black patients between cohorts (p <.001). After adjusting for age, body mass index, American Society of Anesthesiologists class, previous surgery, and uterine weight, disparities by race were no longer present in the postintervention cohort. Perioperative outcomes including length of stay (p <.001), infection rates (p = .002), and blood loss (p = .01) improved after intervention.

CONCLUSION

Increasing fellowship in minimally invasive gynecologic surgery-trained gynecologic surgeons and providing more opportunities in robotic/laparoscopic training for academic specialists may improve access to MIH for Black patients and reduce disparities.

A National Database Study on Racial Disparities in Route of Hysterectomy With a Surrogate Control for Uterine Size: A Proposed Quality Metric for Benign Indications

STUDY OBJECTIVE

To investigate the association between race and route of hysterectomy among patients undergoing hysterectomy for abnormal uterine bleeding (AUB) in the absence of uterine myoma disease and excluding malignancy.

DESIGN

A cross-sectional cohort study utilizing the Healthcare Cost and Utilization Project Nationwide Inpatient Sample and National Ambulatory Surgical databases to compare abdominal to minimally invasive routes of hysterectomy.

SETTING

Hospitals and hospital-affiliated ambulatory surgical centers participating in the Healthcare Cost and Utilization Project in 2019.

PATIENTS

A total of 75 838 patients who had undergone hysterectomy for AUB, excluding uterine myoma and malignancy.

INTERVENTIONS

n/a MEASUREMENTS AND MAIN RESULTS: Of the 75 838 hysterectomies performed for AUB in the absence of uterine myomas and malignancy, 10.1% were performed abdominally and 89.9% minimally invasively. After adjusting for confounders, Black patients were 38% more likely to undergo abdominal hysterectomy compared to White patients (OR 1.38, CI 1.12-1.70 p = .002). Black race, thus, is independently associated with open surgery.

CONCLUSION

Despite excluding uterine myomas as a risk factor for an abdominal route of hysterectomy, Black race remained an independent predictor for abdominal versus minimally invasive hysterectomy, and Black patients were found to undergo a disproportionately higher rate of abdominal hysterectomy compared to White patients.

Racial and Ethnic Disparities in Sacrocolpopexy Approach

IMPORTANCE

Racial inequity elevates risk for certain diagnoses and health disparities. Current data show disparities for Black women when comparing open versus minimally invasive hysterectomy. It is unknown if a similar disparity exists in surgical management of pelvic organ prolapse.

OBJECTIVE

The objective of this study was to determine whether racial or ethnic disparities exist for open abdominal versus minimally invasive sacrocolpopexy.

STUDY DESIGN

Cross-sectional data of the Healthcare Cost and Utilization Project National Inpatient Sample and the Nationwide Ambulatory Surgery Sample for the year 2019 was used. Bivariate analysis identified demographic and perioperative differences between abdominal versus minimally invasive sacrocolpopexy, which were compared in a multivariable logistic regression.

RESULTS

Forty-one thousand eight hundred thirty-seven patients underwent sacrocolpopexy: 35,820 (85.6%), minimally invasive sacrocolpopexy, and 6,016, (14.4%) abdominal sacrocolpopexy. In an unadjusted analysis, Black patients were more likely to undergo an abdominal sacrocolpopexy compared to non-Hispanic White patients (OR 2.14, 95% CI 1.16-3.92, P <0.01). Hispanic patients were more likely to undergo abdominal sacrocolpopexy compared to non-Hispanic White patients (OR 1.69, 95% CI 1.26-2.26, P <0.001). Other factors associated with abdominal sacrocolpopexy are zip code quartile, payer status, composite comorbidity score, hospital control, and hospital bed size. In the regression model, Black patients remained more likely to undergo abdominal sacrocolpopexy compared to those who identified as White (aOR 2, 95% CI 1.26-3.16, P < 0.003). Hispanic patients were more likely to undergo abdominal sacrocolpopexy compared to those who identified as White (aOR 1.73, 95% CI 1.31-2.28, P < 0.001).

CONCLUSION

Abdominal sacrocolpopexy was more likely to occur in patients who identified as Black or Hispanic.

Racial Disparities in Surgical Treatment of Uterine Fibroids During the COVID-19 Pandemic

Objective: Analyze the association between race and surgery performed for uterine fibroids during the coronavirus disease 2019 (COVID-19) pandemic. Methods: Retrospective exploratory cross-sectional study of patients with fibroids who underwent surgery during the COVID-19 pandemic. We compared the type of surgery performed (minimally invasive hysterectomy [MIH], uterine-sparing procedure [USP], or total abdominal hysterectomy [TAH]) by White versus non-White patients. Absolute percentage differences were estimated with multinomial logistic regression adjusting for age, body mass index (BMI), parity, comorbidities, and maximum fibroid diameter. Results: Of 350 subjects, the racial composition was 1.7% Asian, 23.4% Black, and 74.9% White. Non-White patients had greater fibroid burden by mean maximum fibroid diameter, mean uterine weight, and mean fibroid weight. Although MIH occurred more frequently among White patients (7.5% points higher [95% confidence interval (CI) = -3.1 to 18.2]), USP and TAH were more commonly conducted for non-White patients (3.4% points higher [95% CI = -10.4 to 3.6] and 4.2% points higher [95% CI = -13.2 to 4.8], respectively). The overall complication rate was 18.6%, which was 6% points lower (95% CI = -15.8 to 3.7) among White patients. Conclusion: During the COVID-19 pandemic at a single-site institution, non-White patients were more likely to undergo a uterine-sparing procedure for surgical treatment of uterine fibroids, abdominal procedures, including both hysterectomy and myomectomy, and experience surgery-related complications.

Associations between race and ethnicity and perioperative outcomes among women undergoing hysterectomy for adenomyosis

OBJECTIVE

To study racial and ethnic disparities among women undergoing hysterectomy performed for adenomyosis across the United States.

DESIGN

A cohort study.

SETTING

Data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2012-2020.

PATIENTS

Patients with an adenomyosis diagnosis.

INTERVENTION

Hysterectomy for adenomyosis.

MAIN OUTCOME MEASURES

Patients were identified using the International Classification of Diseases 9th and 10th editions codes 617.0 and N80.0 (endometriosis of the uterus). Hysterectomies were classified on the basis of the Current Procedural Terminology codes. We compared baseline and surgical characteristics and 30-day postoperative complications across the different racial and ethnic groups. Postoperative complications were classified into minor and major complications according to the Clavien-Dindo classification system.

RESULTS

A total of 12,599 women underwent hysterectomy for adenomyosis during the study period: 8,822 (70.0%) non-Hispanic White, 1,597 (12.7%) Hispanic, 1,378 (10.9%) non-Hispanic Black or African American, 614 (4.9%) Asian, 97 (0.8%) Native Hawaiian or Pacific Islander, and 91 (0.7%) American Indian or Alaska Native. Postoperative complications occurred in 8.8% of cases (n = 1,104), including major complications in 3.1% (n = 385). After adjusting for confounders, non-Hispanic Black race and ethnicity were independently associated with an increased risk of major complications (adjusted odds ratio 1.54, 95% confidence interval [CI] {1.16-2.04}). Laparotomy was performed in 13.7% (n = 1,725) of cases. Compared with non-Hispanic White race and ethnicity, the adjusted odd ratios for undergoing laparoscopy were 0.58 (95% CI 0.50-0.67) for Hispanic, 0.56 (95% CI 0.48-0.65) for non-Hispanic Black or African American, 0.33 (95% CI 0.27-0.40) for Asian, and 0.26 (95% CI 0.17-0.41) for Native Hawaiian or Pacific Islander race and ethnicity.

CONCLUSION

Among women undergoing hysterectomy for postoperatively diagnosed adenomyosis, non-Hispanic Black or African American race and ethnicity were associated with an increased risk of major postoperative complications. Compared with non-Hispanic White race and ethnicity, Hispanic ethnicity, non-Hispanic Black or African American, Asian, Native Hawaiian, or Pacific Islander race and ethnicity were less likely to undergo minimally invasive surgery.

Trends in Early-Stage Cervical Cancer Management in the US: A National Cancer Database Analysis

The Laparoscopic Approach to Cervical Cancer (LACC) trial was published in 2018 and demonstrated that minimally invasive surgery (MIS) yields inferior survival outcomes in early-stage cervical cancer compared to open surgery. This study investigates how the results of the LACC trial have impacted the selection of the primary treatment modality and adjuvant radiation utilization in early-stage cervical cancer. Using the National Cancer Database (NCDB), we compared patients with stage IA2-IB1 cervical cancer before (1/2016-12/2017) and after (1/2019-12/2020) the LACC trial. A total of 7930 patients were included: 4609 before and 3321 after the LACC trial. There was a decline in MIS usage from 67% pre-LACC to 35% thereafter (p < 0.001). In both the pre- and post-LACC periods, patients undergoing radical MIS more frequently had small volume disease (pre-LACC tumors ≤ 2 cm, 48% MIS vs. 41% open, p = 0.023; post-LACC stage IA2, 22% vs. 15%, p = 0.002). Pre-LACC, MIS radical hysterectomy was associated with White race (82% vs. 77%, p = 0.001) and private insurance (63% vs. 54%, p = 0.004), while there was no difference in socioeconomic factors in the post-LACC period. Although the proportion of patients treated with primary chemoradiation remained stable, the post-LACC cohort had a younger median age (52.47 vs. 56.37, p = 0.005) and more microscopic disease cases (13% vs. 5.4%, p = 0.002). There was no difference in the rate of radiation after radical hysterectomy before and after the trial (26% vs. 24%, p = 0.3). Conclusions: Post-LACC, patients were less likely to undergo MIS but received adjuvant radiation at similar rates, and primary chemoradiation patients were younger and more likely to have microscopic disease.

Postoperative Complications After Sling Operations for Incontinence: Is Race a Factor?

IMPORTANCE

Racial and ethnic disparities exist in urogynecologic surgery; however, literature identifying specific disparities after sling operations for stress incontinence are limited.

OBJECTIVE

The objective of this study was to evaluate racial and ethnic disparities in surgical complications within 30 days of midurethral sling operations.

STUDY DESIGN

This retrospective cohort study identified women who underwent an isolated midurethral sling operation between 2014 and 2021 using the American College of Surgeons National Surgical Quality Improvement Program database. Women were stratified by racial and ethnic category to assess the primary outcome, 30-day surgical complications, and the secondary outcome, comparison of urinary tract infections (UTIs).

RESULTS

There were 20,066 patients included. Mean age and body mass index were 53.9 years and 30.8, respectively. More Black or African American women had diabetes and hypertension, and more American Indian or Alaska Native women used tobacco. The only difference in 30-day complications was stroke/cerebrovascular accident, which occurred in only 1 Asian, Native Hawaiian or other Pacific Islander patient (0.1%, P < 0.0001). The most frequent complication was UTI (3.3%). Black or African American women were significantly less likely to have a diagnosis of UTI than non-Hispanic White (P = 0.04), Hispanic White (P = 0.03), and American Indian or Alaska Native women (P = 0.04).

CONCLUSIONS

Surgical complications within 30 days of sling operations are rare. No clinically significant racial and ethnic differences in serious complications were observed. Urinary tract infection diagnoses were lower among Black or African American women than in non-Hispanic White, Hispanic White, and American Indian or Alaska Native women despite a greater comorbidity burden. No known biologic reason exists to explain lower UTI rates in this population; therefore, this finding may represent a disparity in diagnosis and treatment.

Uterine fibroids and longitudinal profiles of the vaginal microbiota in a cohort presenting for transvaginal ultrasound

Bacterial vaginosis, characterized in part by low levels of vaginal Lactobacillus species, has been associated with pro-inflammatory cytokines which could fuel uterine fibroid development. However, prior work on the associations between uterine fibroids and vaginal bacteria is sparse. Most studies have focused on assessment of individual taxa in a single sample. To address research gaps, we sought to compare short, longitudinal profiles of the vaginal microbiota in uterine fibroid cases versus controls with assessment for hormonal contraceptives (HCs), a possible confounder associated with both protection from fibroid development and increases in Lactobacillus-dominated vaginal microbiota. This is a secondary analysis of 83 reproductive-age cisgender women who presented for transvaginal ultrasound (TVUS) and self-collected mid-vaginal swabs daily for 1-2 weeks before TVUS (Range: 5-16 days, n = 697 samples). Sonography reports detailed uterine fibroid characteristics (N = 21 cases). Vaginal microbiota was assessed by 16S rRNA gene amplicon sequencing and longitudinal microbiota profiles were categorized by hierarchical clustering. We compared longitudinal profiles of the vaginal microbiota among fibroid cases and controls with exact logistic regression. Common indications for TVUS included pelvic mass (34%) and pelvic pain (39%). Fibroid cases tended to be older and report Black race. Cases less often reported HCs versus controls (32% vs. 58%). A larger proportion of cases had low-Lactobacillus longitudinal profiles (48%) than controls (34%). In unadjusted analysis, L. iners-dominated and low-Lactobacillus profiles had higher odds of fibroid case status compared to other Lactobacillus-dominated profiles, however these results were not statistically significant. No association between vaginal microbiota and fibroids was observed after adjusting for race, HC and menstruation. Results were consistent when number of fibroids were considered. There was not a statistically significant association between longitudinal profiles of vaginal microbiota and uterine fibroids after adjustment for common confounders; however, the study was limited by small sample size.

Relugolix combination therapy in Black/African American women with symptomatic uterine fibroids: LIBERTY Long-Term Extension study

BACKGROUND

In the LIBERTY Long-Term Extension study, once-daily relugolix combination therapy (40 mg relugolix, estradiol 1 mg, norethindrone acetate 0.5 mg) substantially improved uterine fibroid-associated heavy menstrual bleeding throughout the 52-week treatment period in the overall study population.

OBJECTIVE

Black or African American women typically experience a greater extent of disease and symptom burden of uterine fibroids vs other racial groups and have traditionally been underrepresented in clinical trials. This secondary analysis aimed to assess the efficacy and safety of relugolix combination therapy in the subgroup population of Black or African American women with uterine fibroids in the LIBERTY Long-Term Extension study.

STUDY DESIGN

Black or African American premenopausal women (aged 18-50 years) with uterine fibroids and heavy menstrual bleeding who completed the 24-week randomized, placebo-controlled, double-blind LIBERTY 1 (identifier: NCT03049735) or LIBERTY 2 (identifier: NCT03103087) trials were eligible to enroll in the 28-week LIBERTY Long-Term Extension study (identifier: NCT03412890), in which all women received once-daily, open-label relugolix combination therapy. The primary endpoint of this subanalysis was the proportion of Black or African American treatment responders: women who achieved a menstrual blood loss volume of <80 mL and at least a 50% reduction in menstrual blood loss volume from the pivotal study baseline to the last 35 days of treatment by pivotal study randomized treatment group. The secondary outcomes included rates of amenorrhea and changes in symptom burden and quality of life.

RESULTS

Overall, 241 of 477 women (50.5%) enrolled in the LIBERTY Long-Term Extension study self-identified as Black or African American. In Black or African American women receiving continuous relugolix combination therapy for up to 52 weeks, 58 of 70 women (82.9%; 95% confidence interval, 72.0%-90.8%) met the treatment responder criteria for reduction in heavy menstrual bleeding (primary endpoint). A substantial reduction in menstrual blood loss volume from the pivotal study baseline to week 52 was demonstrated (least squares mean percentage change: 85.0%); 64.3% of women achieved amenorrhea; 59.1% of women with anemia at the pivotal study baseline achieved a substantial improvement (>2 g/dL) in hemoglobin levels; and decreased symptom severity and distress because of uterine fibroid-associated symptoms and improvements in health-related quality of life through 52 weeks were demonstrated. The most frequently reported adverse events during the cumulative 52-week treatment period were hot flush (12.9%), headache (5.7%), and hypertension (5.7%). Bone mineral density was preserved through 52 weeks.

CONCLUSION

Once-daily relugolix combination therapy improved uterine fibroid-associated heavy menstrual bleeding in most Black or African American women who participated in the LIBERTY Long-Term Extension study. The safety and efficacy profile of relugolix combination therapy in Black or African American women was consistent with previously published results from the overall study population through 52 weeks. Findings from this subanalysis will assist shared decision-making by helping providers and Black or African American women understand the efficacy and safety of relugolix combination therapy as a pharmacologic option for the management of uterine fibroid-associated symptoms.

Risk factors for major complications following colorectal resections for endometriosis in the USA

PURPOSE

We aimed to describe the incidence and identify risk factors for the occurrence of short-term major posto-perative complications following colorectal resection for endometriosis.

METHODS

A cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2012-2020. We included patients with a primary diagnosis of endometriosis who underwent colon or rectal resections for endometriosis.

RESULTS

Of 755 women who underwent colorectal resection, 495 (65.6%) had laparoscopic surgery and 260 (34.4%) had open surgery. The major complication rate was 13.5% (n = 102). Women who underwent open surgery had a higher proportion of major complications (n = 53, 20.4% vs. n = 49, 9.9%, p < 0.001). In a multivariable regression analysis, Black race (aOR 95%CI 2.81 (1.60-4.92), p < 0.001), Hispanic ethnicity (aOR 95%CI 3.02 (1.42-6.43), p = 0.004), hypertension (aOR 95%CI 1.89 (1.08-3.30), p = 0.025), laparotomy (aOR 95%CI 1.64 (1.03-3.30), p = 0.025), concomitant enterotomy (aOR 95%CI 3.02 (1.26-7.21), p = 0.013), and hysterectomy (aOR 95%CI 2.59 (1.62-4.15), p < 0.001) were independently associated with major post-operative complications. In a subanalysis of laparoscopies only, Hispanic ethnicity, chronic hypertension, lysis of bowel adhesions, and hysterectomy were independently associated with major complications. In a subanalysis of laparotomies only, Black race and hysterectomy were independently positively associated with the occurrence of major complications.

CONCLUSION

This study provides a current population-based estimate of short-term complications after surgery for colorectal endometriosis in the USA. The identified risk factors for complications can assist during preoperative shared decision-making and informed consent process.

Healthcare disparities and pelvic organ prolapse operative complications: a nationwide analysis

INTRODUCTION AND HYPOTHESIS

The objective of this study was to evaluate the differences in the incidence of peri-operative complications at the time of pelvic organ prolapse (POP) repair based on health care disparities such as race and socioeconomic status.

METHODS

The National Inpatient Sample (NIS) database was queried using ICD-9/-10 codes for patients aged >18 years undergoing POP repair in 2008-2018. Demographic information, Elixhauser Comorbidity Index (ECI), insurance status, and peri-operative complications were extracted. Multivariate weighted logistic regression using the discharge weights from NIS were constructed on binary outcomes. Complications with at least 1% incidence were included in the analysis.

RESULTS

A total of 172,483 POP repair patients were analyzed: 130,022 (75.4%) were white, 10,561 (6.1%) were Black, 21,915 (12.7%) were Hispanic, and 9,985 (5.8%) were of other races. Patients with Medicaid as well as Black, Hispanic, and other races had higher odds of developing postoperative complications such as urinary tract infections, sepsis, and acute renal failure (p value <0.001-0.02). These were also more common in smaller, rural hospitals and with patients with an annual income of $45,999 or less (p value <0.001-0.03). Black and Hispanic patients had lower odds of intraoperative complications such as hemorrhage (aOR 0.77, 95% CI 0.71-0.84; aOR 0.75, 95% CI 0.7-0.8 respectively) or abdominopelvic injury (aOR 0.86, 95% CI 0.81-0.92; aOR 0.93, 95% CI 0.79-0.88 respectively) compared with white patients.

CONCLUSION

Nonwhite patients with lower socioeconomic status had increased postoperative complications and fewer intraoperative complications from POP surgery, whereas white patients with higher socioeconomic status had more intraoperative complications.

Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review

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.

Risk Factors for Major Complications Following Minimally Invasive Surgeries for Endometriosis in the United States

STUDY OBJECTIVE

To study the rate and risk factors for short-term postoperative complications of patients undergoing minimally invasive surgery (MIS) for endometriosis in the United States.

DESIGN

Retrospective cohort study.

SETTING

American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020.

PATIENTS

Patients with endometriosis diagnosis.

INTERVENTIONS

Laparoscopic surgery for endometriosis.

MEASUREMENTS AND MAIN RESULTS

We compared women with and without 30-day postoperative major complications, defined according to the Clavien-Dindo classification. A total of 28 697 women underwent MIS during the study period, of which 2.6% had major postoperative complications. Organ space surgical site infection and reoperation were the most common complications (47.0% and 39.8%, respectively). In multivariable regression analysis, African American race (adjusted odds ratio [aOR] 95% confidence interval [CI] 1.61 [1.29-2.01], p <.001), hypertension (aOR 95% CI 1.23 [1.01-1.50], p = .036), bleeding disorders (aOR 95% CI 1.96 [1.03-3.74], p = .041), bowel procedures (aOR 95% CI 1.93 [1.37-2.72], p <.001) and hysterectomy (aOR 95% CI 2.09 [1.67-2.63], p <.001) were independently associated with increased risk of major complications. In multivariable regression analysis of laparoscopies without bowel procedures, African American race, bleeding disorders, and hysterectomy were independently associated with increased major complication risk. Among cases with bowel procedures, African American race and colectomy were independently associated with increased major complication risk. In multivariable regression analysis of women who underwent hysterectomy, African American race, bleeding disorders, and lysis of adhesions were independently associated with increased major complications risk. Among women who underwent uterine-sparing surgery, African American race, hypertension, preoperative blood transfusion, and bowel procedures were independently associated with increased major complications risk.

CONCLUSION

Among women undergoing MIS for endometriosis, African American race, hypertension, bleeding disorders, and bowel surgery or hysterectomy are risk factors for major complications. African American race is a risk factor for major complications among women undergoing surgeries with and without bowel procedures or hysterectomy.

Transcending Language Barriers in Obstetrics and Gynecology: A Critical Dimension for Health Equity

There is growing evidence that language discordance between patients and their health care teams negatively affects quality of care, experience of care, and health outcomes, yet there is limited guidance on best practices for advancing equitable care for patients who have language barriers within obstetrics and gynecology. In this commentary, we present two cases of language-discordant care and a framework for addressing language as a critical lens for health inequities in obstetrics and gynecology, which includes a variety of clinical settings such as labor and delivery, perioperative care, outpatient clinics, and inpatient services, as well as sensitivity around reproductive health topics. The proposed framework explores drivers of language-related inequities at the clinician, health system, and societal level. We end with actionable recommendations for enhancing equitable care for patients experiencing language barriers. Because language and communication barriers undergird other structural drivers of inequities in reproductive health outcomes, we urge obstetrician-gynecologists to prioritize improving care for patients experiencing language barriers.

Trends in surgical approach to hysterectomy and perioperative outcomes in Michigan hospitals from 2010 through 2020

The objective of this study was to determine the trends in surgical approach to hysterectomy over the last decade and compare perioperative outcomes and complications. This retrospective cohort study used clinical registry data from the Michigan Hospitals that participated in Michigan Surgical Quality Collaborative (MSQC) from January 1st, 2010 through December 30th, 2020. A multigroup time series analysis was performed to determine how surgical approach to hysterectomy [open/TAH, laparoscopic (TLH/LAVH), and robotic-assisted (RA)] has changed over the last decade. Abnormal uterine bleeding, uterine fibroids, chronic pelvic pain, pelvic organ prolapse, endometriosis, pelvic mass, and endometrial cancer were the most common indications for hysterectomy. The open approach to hysterectomy declined from 32.6 to 16.9%, a 1.9-fold decrease, with an average decline of 1.6% per year (95% CI - 2.3 to - 0.9%). Laparoscopic-assisted hysterectomies decreased from 27.2 to 23.8%, a 1.5-fold decrease, with an average decrease of 0.1% per year (95% CI - 0.7 to 0.6%). Finally, the robotic-assisted approach increased from 38.3 to 49.3%, a 1.25-fold increase, with an average of 1.1% per year (95% CI 0.5 to 1.7%). For malignant cases, open procedures decreased from 71.4 to 26.6%, a 2.7-fold decrease, while RA-hysterectomy increased from 19.0 to 58.7%, a 3.1-fold increase. After controlling for the confounding variables age, race, and gynecologic malignancy, RA hysterectomy was found to have the lowest rate of complications when compared to the vaginal, laparoscopic and open approaches. Finally, after controlling for uterine weight, black patients were twice as likely to undergo an open hysterectomy compared to white patients.

The Influence of Race/Ethnicity on the Transcriptomic Landscape of Uterine Fibroids

The objective of this study was to determine if the aberrant expression of select genes could form the basis for the racial disparity in fibroid characteristics. The next-generation RNA sequencing results were analyzed as fold change [leiomyomas/paired myometrium, also known as differential expression (DF)], comparing specimens from White (n = 7) and Black (n = 12) patients. The analysis indicated that 95 genes were minimally changed in tumors from White (DF ≈ 1) but were significantly altered by more than 1.5-fold (up or down) in Black patients. Twenty-one novel genes were selected for confirmation in 69 paired fibroids by qRT-PCR. Among these 21, coding of transcripts for the differential expression of FRAT2, SOX4, TNFRSF19, ACP7, GRIP1, IRS4, PLEKHG4B, PGR, COL24A1, KRT17, MMP17, SLN, CCDC177, FUT2, MYO5B, MYOG, ZNF703, CDC25A, and CDCA7 was significantly higher, while the expression of DAB2 and CAV2 was significantly lower in tumors from Black or Hispanic patients compared with tumors from White patients. Western blot analysis revealed a greater differential expression of PGR-A and total progesterone (PGR-A and PGR-B) in tumors from Black compared with tumors from White patients. Collectively, we identified a set of genes uniquely expressed in a race/ethnicity-dependent manner, which could form the underlying mechanisms for the racial disparity in fibroids and their associated symptoms.

Racial Disparities in Hysterectomy Route for Benign Disease: Examining Trends and Perioperative Complications from 2007 to 2018 Using the NSQIP Database

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.

Hysterectomy inequities between black and white patients in the US military health system: A retrospective cohort study

OBJECTIVE

To evaluate multicomponent aspects of hysterectomy-related care in the US Military Health System including the probability of open hysterectomy (versus vaginal or laparoscopic hysterectomy), probability of having a length of stay > 1 day, and discharge milligram morphine equivalent dose (MED). Analyses sought to identify the presence and strength of healthcare inequities between Black and white patients.

METHODS

In this retrospective cohort study, records of patients (N = 11,067) ages 18-65 years enrolled in TRICARE who underwent a hysterectomy between January 2017 to January 2021 in US military treatment facilities (direct care) or civilian facilities (purchased care) were included. Graphic representations illustrated provider and facility variation. Generalized additive mixed models (GAMMs) evaluated inequities across outcomes. Sensitivity analyses included only direct care receipt and added a random effect for the facility.

RESULTS

There was significant variation in provider use of open versus vaginal or laparoscopic hysterectomies, as well as provider and facility discharge MED. The GAMMs indicated Black patients were more likely to receive an open hysterectomy [log(OR) -0.54, (95 %CI -0.65, -0.43), p < 0.001] and have a length of stay > 1 day [log(OR) 0.18, (95 %CI 0.07, 0.30), p = 0.002], but had similar discharge MED [-2 mg (95% CI -7 mg, 3 mg), p = 0.51], relative to white patients. Patients receiving care in purchased care, relative to direct care, were more likely to receive a vaginal or laparoscopic hysterectomy [log(OR) 0.28, (95 %CI 0.17, 0.38), p = 0.002] and received approximately 21 mg lower discharge MED (95 %CI 16-26 mg less, p < 0.001), but were more likely to have a hospital stay > 1 day [log(OR) 0.95, (95 %CI 0.83, 0.1.10), p < 0.001]. Additional gynecological conditions (e.g., uterine fibroids) and prescription receipt were associated with some, but not all outcomes.

CONCLUSION

Improving timely care receipt, especially for uterine fibroids, increasing access to vaginal and laparoscopic hysterectomies, and reducing unwarranted variation in discharge MED could improve care quality and equity in the US Military Health System.

Minimally invasive interval debulking surgery for advanced ovarian cancer after neoadjuvant chemotherapy

OBJECTIVE

Assess outcomes of interval debulking surgery (IDS) after neoadjuvant chemotherapy via minimally invasive surgery (MIS) compared with laparotomy in patients with advanced epithelial ovarian cancer.

METHODS

Patients diagnosed with stage IIIC or IV epithelial ovarian cancer between 2013 and 2018 who received neoadjuvant chemotherapy and IDS were identified in the National Cancer Database. Primary outcome was overall survival. Secondary outcomes were 5-year survival, 30- and 90-day postoperative mortality, extent of surgery, residual disease, hospitalization duration, surgical conversions, and unplanned readmissions. Propensity score matching was used to compare MIS and laparotomy for IDS. Association of treatment approach with overall survival was assessed using Kaplan-Meier method and Cox regression. Sensitivity analysis was conducted for effect of unmeasured confounders.

RESULTS

A total of 7897 patients met inclusion criteria; 2021 (25.6%) underwent MIS. Percentage undergoing MIS increased from 20.3%-29.0% over the study period. After propensity score matching, median overall survival was 46.7 months in the MIS group versus 41.0 months in the laparotomy group [hazard ratio (HR) 0.86 (95%CI 0.79-0.94)]. Five-year survival probability was higher in MIS versus laparotomy (38.3% vs 34.8%, p < 0.01). There was lower 30- and 90-day mortality (0.3% vs 0.7% [p = 0.04] and 1.4% vs 2.5% [p = 0.01], respectively), shorter length of stay (median 3 vs 5 days, p < 0.01), lower residual disease (23.9% vs 26.7%, p < 0.01), and lower additional cytoreductive procedures (59.3% vs 70.8%, p < 0.01) in MIS compared to laparotomy, with similar rates of unplanned readmission (2.7% vs 3.1%, p = 0.39).

CONCLUSIONS

Patients who undergo IDS by MIS have similar overall survival and decreased morbidity compared with laparotomy.

Disparities in Women With Endometriosis Regarding Access to Care, Diagnosis, Treatment, and Management in the United States: A Scoping Review

Endometriosis is a benign gynecological condition that elicits chronic pain in 2-10% of reproductive-age women in the United States and exists in approximately 50% of women with infertility. It creates complications such as hemorrhage and uterine rupture. Historically, the gynecologic symptoms of endometriosis have been associated with economic strain and inferior quality of life. It is suspected that endometriosis diagnosis and treatment are affected by health disparities throughout gynecological care. The goal of this review was to collate and report the current evidence on potential healthcare disparities related to endometriosis diagnosis, treatment, and care across race, ethnicity, and socioeconomic status. This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and searched the Excerpta Medica Database (EMBASE), Medline Ovid, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and PsycInfo databases for relevant articles on the topic. Eligibility was established a priori to include articles written in English, published between 2015-2022, and reported on cohort, cross-sectional, or experimental studies conducted in the United States. Initially, 328 articles were found, and after screening and quality assessment, four articles were retained for the final review. Results indicated that White women had higher rates of minimally invasive procedures versus open abdominal surgeries than non-White women. White women also had fewer surgical complications compared to all other races and ethnicities. Black women had higher rates of perioperative complications, higher mortality, and spent more time in the perioperative stage than any other race or ethnicity. In the management of endometriosis, the limited research available showed that all non-White women encountered an increased risk of perioperative and postoperative complications compared to White women. More research is needed to explore diagnostic and treatment disparities beyond surgical management, socioeconomic barriers, and improved representation of racial and ethnic minority women.

Comparison of Enhanced Recovery After Surgery (ERAS) metrics by race among gynecologic oncology patients: Ensuring equitable outcomes

OBJECTIVES

Race and ethnicity are not routinely audited in Enhanced Recovery After Surgery (ERAS) pathways. Given known racial disparities in outcomes in gynecologic oncology, the purpose of this study was to compare differences in ERAS implementation and outcomes by race.

METHODS

A cohort study was performed among gynecologic oncology patients enrolled in an ERAS pathway at one academic institution from March 2017 to December 2021. Compliance with ERAS metrics, postoperative complications, 30-day survival, reoperations, intensive care unit (ICU) transfers, and readmissions within 30 days were compared by race.

RESULTS

Of 1083 patients (17.0% non-white), non-white women were younger (54.2 years ±13.1 vs. 60.7 years ±13.6, p < 0.001) and proportionally fewer spoke English (75.0% vs. 97.8%, p < 0.001). Fewer non-white women received preadmission ERAS education (73.4% vs. 79.9%, p = 0.05). There were no differences in ERAS implementation by race, including similar rates of preoperative nutritional assessment, carbohydrate loading, antibiotic and thrombosis prophylaxis, and unplanned surgeries by race. There were no differences in complications, reoperations, ICU transfers, or readmissions by race on univariate and multivariate analysis. Four non-white (2.2%) and two white women (0.2%, p = 0.009) died within 30 days of surgery.

CONCLUSIONS

Fewer non-white women received preadmission education, possibly due to language barriers. ERAS compliance, postoperative complications, readmissions, reoperations, and ICU transfers did not differ by race. There were two additional deaths within 30 days postoperatively among non-white women compared to white women - which is difficult to interpret given the rarity of perioperative mortality - but appeared unlikely to be related to differences in ERAS protocol implementation. ERAS programs should ensure educational materials are translated into various languages and audit metrics by race to ensure equitable outcomes.

Exploratory study of race- or ethnicity-based discrimination among patients receiving procedural abortion care

OBJECTIVE

Explore relationships of race and ethnicity with experiences of race- or ethnicity-based discrimination during abortion care.

STUDY DESIGN

English- or Spanish-speaking individuals aged 18 to 50 completed cross-sectional, self-administered online surveys within 30 days of procedural abortion at 5 Northeastern U.S. reproductive health clinics from June 2020 toFebruary 2021. We considered any affirmative response on the Discrimination in Medical Settings (DMS) scale evidence of race- or ethnicity-based discrimination. We performed bivariate analyses and logistic regression examining discrimination among Black non-Latinx, Latinx any race, Other race non-Latinx compared to White non-Latinx participants. We assessed associations between discrimination and healthcare quality and satisfaction.

RESULTS

Participants (n = 163) averaged 27(±6) years and self-identified as Black non-Latinx (36.2%), White non-Latinx (28.8%), Latinx of any race (27.0%), and Other non-Latinx (8.0%). Most were publicly insured (52.8%) and <14 weeks gestation (90.8%).Overall, 15.3% reported race- or ethnicity-based discrimination during abortion care with Black non-Latinx more likely to report discrimination (23.7%; OR 7.00, 95% CI 1.50-32.59), while Latinx any race (15.9%, OR 4.26, 95% CI 0.83-21.74) and Other race non-Latinx participants (15.4%, OR 4.09, 95% CI 0.52-32.35) demonstrated statistically nonsignificant trend toward increased odds of discrimination compared to White non-Latinx (4.3%). Discrimination was associated with negative perceptions of: time with physician (p = 0.03), patient care involvement (p < 0.05), physician communication (p = 0.01), care quality (p = 0.02), and care satisfaction (p < 0.01).

CONCLUSION

Racially minoritized participants were more likely to report race- or ethnicity-based discrimination during abortion care; Black non-Latinx reported highest odds of discrimination compared to White non-Latinx. Discrimination was associated with unfavorable healthcare quality measures.

IMPLICATIONS

Race- or ethnicity-based discrimination during abortion care is disproportionately reported by racially minoritized populations, especially Black individuals, compared to White non-Latinx individuals. Discrimination is significantly associated with negative experiences of care. Future work should verify findings in different regions and larger studies, and design and test discrimination-reduction interventions.

Efficacy of Tubal Surgery for Permanent Contraception: Considerations for the Clinician

Permanent contraception meets the needs of many people certain in their decision to never become pregnant in the future. Female permanent contraception procedures became more common than male procedures during the 1970s and 1980s, when laparoscopic surgery became widely available. To better understand the efficacy of these new procedures, the US Centers for Disease Control and Prevention conducted a prospective cohort study, known as the Collaborative Review of Sterilization (CREST). For decades, results of this study have defined perioperative counseling around failure risks of such surgeries. However, laparoscopic technology and techniques have changed significantly in recent decades and evidence has emerged supporting noncontraceptive benefits of tubal excision. Therefore, we present here a review of updated information regarding permanent contraception failure in the modern context and implications for clinical practice and future research directions.

Racial disparities in uterine fibroids and endometriosis: a systematic review and application of social, structural, and political context

IMPORTANCE

Uterine fibroids and endometriosis are 2 of the leading causes of morbidity among reproductive-aged women. There are significant racial disparities in disease prevalence, incidence, age of onset, and treatment profile in fibroids. The data on endometriosis are less clear.

OBJECTIVE

To conduct a systematic review of racial disparities in prevalence of uterine fibroids and endometriosis in the United States and summarize the literature on these 2 highly prevalent benign gynecologic conditions using a framework that explicitly incorporates and acknowledges the social, structural, and political contexts as a root cause of racial disparities between Black and White women.

EVIDENCE REVIEW

A systematic review regarding racial disparities in prevalence of fibroids and endometriosis was conducted separately. Two separate searches were conducted in PubMed to identify relevant original research manuscripts and prior systematic reviews regarding racial disparities in uterine fibroids and endometriosis using standardized search terms. In addition, we conducted a structured literature search to provide social, structural, and political context of the disparities.

FINDINGS

A systematic review of the literature indicated that the prevalence of uterine fibroids was consistently higher in Black than in White women with the magnitude of the difference varying depending on population and case definition. Prevalence of endometriosis varied considerably depending on the base population and case definition, but was the same or lower among Black vs. White women. As a result of the social, structural, and political context in the United States, Black women disproportionately experience a range of exposures across the life course that may contribute to their increased uterine fibroid incidence, prevalence, and severity of uterine fibroids. However, data suggest no racial difference in the incidence of endometriosis. Nevertheless, Black women with fibroids or endometriosis experience worse clinical and surgical outcomes than their White counterparts.

CONCLUSION AND RELEVANCE

Racial disparities in uterine fibroids and endometriosis can be linked with differential exposures to suspected etiologic agents, lack of adequate access to health care, including highly skilled gynecologic surgeons, and bias and discrimination within the health care system. Eliminating these racial disparities will require solutions that address root causes of health disparities through policy, education and programs to ensure that all patients receive culturally- and structurally-competent care.

Disparities in Benign Gynecologic Surgical Care

A person's health is not only affected by their disease states, but also the quality of care and posttreatment sequelae. Research shows that disparities exist in benign gynecologic surgery access to care, techniques, and perioperative outcomes. Surgical education, pathways that emphasize minimally invasive approaches, and patient-centered care that recognizes historical influences on patient perspectives are critical to dampening these disparities.

Structural Gynecological Disease: Fibroids, Endometriosis, Ovarian Cysts

Fibroids, endometriosis, and ovarian cysts are common conditions. Fibroids can be asymptomatic or present with heavy menstrual bleeding, pelvic pressure, and pain. Endometriosis is a common cause of cyclical pelvic pain. Ovarian cysts are generally diagnosed incidentally. Transvaginal ultrasound is the performed imaging modality for all structural gynecological disease. Symptomatic management is recommended for each condition. Fibroids can be managed medically or surgically depending on the patient's symptoms and desire for future fertility. Nonsteroidal anti-inflammatory drugs are the first-line therapy for endometriosis followed by oral contraceptives and surgical management. Ovarian cysts can be managed expectantly.

Who Places High Value on the Uterus? A Cross-sectional Survey Study Evaluating Predictors for Uterine Preservation

STUDY OBJECTIVE

To determine predictors for placing high value on the uterus in patients who no longer desire fertility. The secondary objective was to identify reasons for placing high value on the uterus.

DESIGN

Cross-sectional survey study.

SETTING

Three hospitals within a large healthcare system in the United States.

PATIENTS

New patients ≥45 years old seeking care for benign gynecologic conditions, including abnormal uterine bleeding, uterine myomas, pelvic organ prolapse, endometriosis, or pelvic pain.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the summative score of the validated Value of Uterus (VALUS) instrument for measuring value placed on the uterus and the validated visual analog scale with the question "how important is it to you to keep your uterus when you have a gynecologic condition?" A total of 163 surveys were returned for analysis (79.2%). Using the VALUS cutoff, 64 patients (45.7%) were considered to have low value for their uterus (VALUS score <14), whereas 76 patients (54.3%) were considered to have high value for their uterus (VALUS score ≥14). The adjusted odds of placing high value for the uterus was 5.06 times higher among those who wanted to be sexually active in the future than those who do not desire to be sexually active (95% confidence interval, 1.55-16.52, p = .01). Patients who are sexually active have 3.94 higher adjusted odds of placing high value on the uterus than those who are not sexually active and do not desire to be (95% confidence interval, 1.36-11.43; p = .01). Race, religion, and personal history of cancer were not statistically significant.

CONCLUSION

Patients who highly value the uterus were highly motivated by the desire to be sexually active. Nonwhite race, religion, and personal history of cancer were not predictors for placing high value on uterine preservation.

Impact of Race and Ethnicity on Perioperative Outcomes During Hysterectomy for Endometriosis

STUDY OBJECTIVE

To assess whether complications incurred during hysterectomy for the treatment of endometriosis differ among racial-ethnic groups.

DESIGN

Retrospective cohort study.

SETTING

American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2019. This database is a robust, comprehensive, multi-institutional database with nearly 700 participating hospitals.

PATIENTS

Patients with a diagnosis of endometriosis or with an endometriosis-associated symptom as the primary indication for surgery and surgical intraoperative documentation of endometriosis.

INTERVENTIONS

Compare perioperative complications based on patient race and ethnicity.

MEASUREMENTS AND MAIN RESULTS

A total of 5639 patients underwent hysterectomy for endometriosis; of these, 4368 were White patients (77.5%), 528 Black patients (9.4%), 491 Hispanic patients (8.7%), 252 Asian patients (4.5%). There was no association between location of endometriosis and patient race and ethnicity. However, White patients had highest rate, and Asian patients had the lowest rate of laparoscopic hysterectomy, 85.3% vs 69.8%, respectively (p <.01). In addition, there were differences in concomitant procedures performed at time of hysterectomy based on race and ethnicity, with White patients having the highest rates of adnexal/peritoneal surgery at 12.5% (p <.01) compared with patients of the other racial and ethnic groups. Asian patients had the highest rate of ureteral surgery at 6.8% (p <.01) and highest rate of intestinal surgery at 16.3% (p <.01) compared with patients of other racial and ethnic groups. There was no association of rates of concomitant bladder surgery, appendectomy, or rectal surgery with patient race and ethnicity. Black patients had the highest rate of minor complications at 13.5% (p <.01) and the highest rate of major complications at 6.6% (p <.01) compared with patients of other racial and ethnic groups. After multivariable analysis, Black patients still had increased odds of having a major complication compared with patients of other racial and ethnic groups even after controlling for patient characteristics and perioperative factors such as endometriosis lesion location, surgical approach, and concomitant procedures (odds ratio 1.64; 95% confidence interval, 1.10-2.45).

CONCLUSION

Endometriosis lesion location did not differ with patient race and ethnicity. However, patient race and ethnicity did have an impact on the surgical approach and the concomitant surgical procedures performed at time of hysterectomy. Black patients had the highest odds of major complications.

Dismantling Structural Barriers: Resident Clinics Refocused on Equity

Disparities in health by race, ethnicity, and socioeconomic status within obstetrics and gynecology are well described and prompt evaluation for structural barriers. Academic medicine has a historical role in caring for marginalized populations, with medical trainees often serving as first-line clinicians for outpatient care. The ubiquitous approach of concentrating care of marginalized patients within resident and trainee clinics raises ethical questions regarding equity and sends a clear message of value that is internalized by learners and patients. A path forward is elimination of the structural inequities caused by maintenance of clinics stratified by training level, thereby creating an integrated patient pool for trainees and attending physicians alike. In this model, demographic and insurance information is blinded and patient triage is guided by clinical acuity and patient preference alone. To address structural inequities in our health care delivery system, we implemented changes in our department. Our goals were to improve access and patient experience and to send a unified message to our patients, learners, and faculty-our clinical staff, across all training levels, are committed to giving the highest standard of care to all people, regardless of insurance status or ability to pay. Academic medical centers must look internally for structural barriers that contribute to health care disparities within obstetrics and gynecology as we aim to make progress toward equity.

The Impact of Race and Ethnicity on Use of Minimally Invasive Surgery for Myomas

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.

ACR Appropriateness Criteria® Fibroids

Uterine fibroids (leiomyomas or myomas) are the most common neoplasm of the uterus. Though incompletely understood, fibroid etiology is multifactorial, a combination of genetic alterations and endocrine, autocrine, environmental, and other factors such as race, age, parity, and body mass index. Black women have greater than an 80% incidence of fibroids by age 50, whereas White women have an incidence approaching 70%. Fibroid symptoms are protean, and menorrhagia is most frequent. The societal economic burden of symptomatic fibroids is large, 5.9 to 34.3 billion dollars annually. There are a variety of treatment options for women with symptomatic fibroids ranging from medical therapy to hysterectomy. Myomectomy and uterine fibroid embolization are the most common uterine sparing therapies. Pelvic ultrasound (transabdominal and transvaginal) with Doppler and MRI with and without intravenous contrast are the best imaging modalities for the initial diagnosis of fibroids, the initial treatment of known fibroids, and for surveillance or posttreatment imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Predicting major complications in patients undergoing laparoscopic and open hysterectomy for benign indications

BACKGROUND

Hysterectomy, the most common gynecological operation, requires surgeons to counsel women about their operative risks. We aimed to develop and validate multivariable logistic regression models to predict major complications of laparoscopic or abdominal hysterectomy for benign conditions.

METHODS

We obtained routinely collected health administrative data from the English National Health Service (NHS) from 2011 to 2018. We defined major complications based on core outcomes for postoperative complications including ureteric, gastrointestinal and vascular injury, and wound complications. We specified 11 predictors a priori. We used internal-external cross-validation to evaluate discrimination and calibration across 7 NHS regions in the development cohort. We validated the final models using data from an additional NHS region.

RESULTS

We found that major complications occurred in 4.4% (3037/68 599) of laparoscopic and 4.9% (6201/125 971) of abdominal hysterectomies. Our models showed consistent discrimination in the development cohort (laparoscopic, C-statistic 0.61, 95% confidence interval [CI] 0.60 to 0.62; abdominal, C-statistic 0.67, 95% CI 0.64 to 0.70) and similar or better discrimination in the validation cohort (laparoscopic, C-statistic 0.67, 95% CI 0.65 to 0.69; abdominal, C-statistic 0.67, 95% CI 0.65 to 0.69). Adhesions were most predictive of complications in both models (laparoscopic, odds ratio [OR] 1.92, 95% CI 1.73 to 2.13; abdominal, OR 2.46, 95% CI 2.27 to 2.66). Other factors predictive of complications included adenomyosis in the laparoscopic model, and Asian ethnicity and diabetes in the abdominal model. Protective factors included age and diagnoses of menstrual disorders or benign adnexal mass in both models and diagnosis of fibroids in the abdominal model.

INTERPRETATION

Personalized risk estimates from these models, which showed moderate discrimination, can inform clinical decision-making for people with benign conditions who may require hysterectomy.

Racial and ethnic disparities in the surgical management of tubal ectopic pregnancy

Objective

To evaluate racial and ethnic disparities in the surgical management of ectopic pregnancy over time.

Design

Retrospective cohort study.

Setting

None.

Patients

Surgically-managed cases of patients with tubal ectopic pregnancy within the American College of Surgeons National Surgical Quality Improvement Program database between 2010 and 2019.

Interventions

None.

Main outcome measures

Surgical approach (laparoscopic compared with open) and procedure (salpingectomy compared with salpingostomy/other).

Results

Of 7791 patients undergoing surgical management of tubal ectopic pregnancy, 21.8% identified as Hispanic, 24.5% as Black, 9.4% as Asian/other, and 44.3% as White. Use of laparoscopy increased 1.3% per year from 81.4% in 2010 to 91.0% in 2019 (95% confidence interval [CI], 0.010-0.016). Odds of undergoing laparoscopic surgery were lower in Black (adjusted odds ratio [aOR] 0.52; 95% CI, 0.45-0.61) and Hispanic patients (aOR 0.52; 95% CI, 0.44-0.61) compared with White patients and remained similar over time. The use of salpingectomy increased by 1.1% per year from 80.6% in 2010 to 94.7% in 2019 (95% CI, 0.009-0.014). Odds of undergoing salpingectomy were higher among Black (aOR 1.78, 95% CI 1.43-2.23) and Hispanic patients (aOR 1.54; 95% CI, 1.24-1.93) and lower among Asian patients (aOR 0.73, 95% CI, 0.56-0.95) compared with White patients. These ratios remained similar for Black and Asian patients over time.

Conclusions

Despite the increased use of laparoscopy and salpingectomy in the surgical management of ectopic pregnancy over time, Black and Hispanic patients remain less likely to undergo minimally invasive surgery and more likely to undergo salpingectomy compared with White patients.

Perceptions of Ethnoracial Factors in the Management and Treatment of Uterine Fibroids

BACKGROUND

Uterine fibroids are non-cancerous neoplasms of the uterus. Women of color, including non-Hispanic Black/African American women and Hispanic/Latinas, have a higher uterine fibroid prevalence, incidence, and disease burden compared to non-Hispanic White women. Therefore, understanding ethnoracial factors in the diagnosis and treatment of uterine fibroids in women of color is critical. This study provides insight on the ethnoracial factors and cultural barriers experienced by women of color in the management and treatment of uterine fibroids.

METHODS

Women were recruited via The Fibroid Foundation, a nonprofit that provides uterine fibroid support and education. Women who were interested completed an online screening survey. Eligible participants were interviewed via phone. Transcribed audio recordings were qualitatively analyzed using the principles of grounded theory.

RESULTS

Forty-seven women of reproductive age who were diagnosed with uterine fibroids and received U.S.-based care participated in a semi-structured interview exploring experiences with uterine fibroid diagnosis and management. Twenty-eight women self-identified as Black, Latina, or other ethnicity. Women of color reported fibroid symptoms that significantly disrupted their work and home life. Women of color also reported perceptions that their race/ethnicity impacted their uterine fibroid treatment, including negative interpersonal provider-patient interactions. These perceptions engendered feelings of skepticism towards the medical system based on historical injustices and/or their own negative experiences and led some to go without longitudinal care.

CONCLUSION

Cultural and familial factors have significant impact on uterine fibroid diagnosis and management. Greater attention to culturally sensitive care and potential bias reduction in the treatment of uterine fibroids should be a priority.

Social Vulnerability Index and Surgical Management of Abnormal Uterine Bleeding in Reproductive-Age Women

STUDY OBJECTIVE

To determine whether surgical management of abnormal uterine bleeding (AUB) is associated with Social Vulnerability Index (SVI).

DESIGN

Retrospective cohort.

SETTING

Seven hospitals and four ambulatory surgery centers within large New York health system.

PATIENTS

All patients 15-45 years of age who underwent either a hysterectomy or myomectomy for AUB between January 2019 and October 2021.

INTERVENTIONS

None. Home addresses were linked to Census tracts and SVI scores. SVI is composed of 4 themes that potentially influence a community's vulnerability to health stressors: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. Multiple logistic regression analyses were performed to evaluate the association between SVI and surgical procedure/approach, adjusting for: age, race and ethnicity, marital status, insurance, language, body mass index, and prior abdominal surgery.

MEASUREMENTS AND MAIN RESULTS

A total of 1,628 patients were included. On regression analysis between SVI quarters and type of surgery, the odds of laparotomy for the hysterectomy group were not impacted by SVI composite score both before and after adjusting for alternative factors (OR and aOR). Amongst those who had a myomectomy, individuals in SVI Q3 had 1.86 (95% CI: 1.27 to 2.72) higher odds of having a laparotomy versus those in SVI Q1. Individuals in SVI Q4 had 1.74 (95% CI: 1.15 to 2.62) higher odds of having a laparotomy versus those in SVI Q1. While some unadjusted odds ratios were statistically significant in the myomectomy group, when adjusted for social, demographic and economic factors the results were not statistically significant.

CONCLUSION

Patients living in more vulnerable communities are less likely to have minimally invasive hysterectomy or myomectomy for management of AUB. Neighborhood characteristics are independently associated with surgical procedure and approach.

Considerations for the Use of Race in Research in Obstetrics and Gynecology

The race variable in research has been the topic of debate in both research and clinical realms. The tension surrounding the discourse of the use of race in research stem from the difficulties in defining race, the limitations of the variable, and the implications for health and racial equity. In this review, we dissect the challenges faced when incorporating race into research and offer a guide for incorporating race in research in a manner that promotes racial and health equity.

Racial and ethnic differences in the adoption of opportunistic salpingectomy for ovarian cancer prevention in the United States

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 ratio_2011-2013, 0.80 [95% confidence interval, 0.73-0.88]; risk ratio_2014-2018, 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.

Effect of Intelligent Medical Management Platform Combined with Perioperative Detailed Nursing on Cognitive Ability, Postoperative Complications, and Quality of Life of Patients Undergoing Hysterectomy

Objective. To analyze the effect of an intelligent medical management platform combined with perioperative detailed nursing on cognitive ability, postoperative complications, and quality of life (QOL) of patients undergoing hysterectomy. Methods. The clinical data of 76 patients undergoing hysterectomy in our hospital from December 2019 to December 2021 were selected for the retrospective analysis, and the patients were divided into the experimental group (EG, $n=38$ , intelligent medical management platform+perioperative detailed nursing) and the routine group (RG, $n=38$ , routine nursing) according to their admission order, and the cognition of disease and QOL after intervention of patients in the two groups were evaluated by the self-proposed questionnaire on cognition of disease of our hospital and the MOS 36-item short-form health survey (SF-36). Results. After intervention, the scores on cognitive ability, various nursing items, and QOL were significantly higher in EG than in RG ( $P<0.001$ ), and during the study, the total incidence rate of complications was significantly lower in EG than in RG ( $P<0.05$ ). Conclusion. Combining an intelligent medical management platform with perioperative detailed nursing is a reliable method to improve QOL and reduce postoperative complications for patients undergoing hysterectomy. Further research will be conducive to providing a reliable perioperative intervention scheme for such patients.

Cultural Competency Curricula in US Graduate Medical Education: A Scoping Review

BACKGROUND

Cultural competency training provides participants with knowledge and skills to improve cross-cultural communication and is required for all graduate medical education (GME) training programs.

OBJECTIVE

The authors sought to determine what cultural competency curricula exist specifically in GME.

METHODS

In April 2020, the authors performed a scoping review of the literature using a multidatabase (PubMed, Ovid, MedEdPORTAL) search strategy that included keywords relevant to GME and cultural competency. The authors extracted descriptive data about the structure, implementation, and analysis of cultural competency curricula and analyzed these data for trends.

RESULTS

Sixty-seven articles met criteria for inclusion, of which 61 (91%) were focused exclusively on residents. The most commonly included specialties were psychiatry (n=19, 28.4%), internal medicine (n=16, 23.9%), and pediatrics (n=15, 22.4%). The shortest intervention was a 30-minute online module, while the longest contained didactics, electives, and mentoring programs that spanned the entirety of residency training (4 years). The sample sizes of included studies ranged from 6 to 833 participants. Eight (11.9%) studies utilized OSCEs as assessment tools, while 17 (25.4%) conducted semi-structured interviews or focus groups. Four common themes were unique interventions, retention of learning, trainee evaluation of curricula, and resources required for implementation.

CONCLUSIONS

Wide variation exists in the design, implementation, and evaluation of cultural competency curricula for residents and fellows.

Racial Disparity in the Surgical Management of Diverticular Disease

INTRODUCTION

Although minimally invasive surgery (MIS) has clearly been associated with improved colorectal surgery outcomes, not all populations benefit from this approach. Using a national database, we analyzed both, the trend in the utilization of MIS for diverticulitis and differences in utilization by race.

METHODS

Colon-targeted participant user files (PUFs) from 2012 to 18 were linked to respective PUFs in National Surgical Quality Improvement Project. Patients undergoing colectomy for acute diverticulitis or chronic diverticular disease were included. Surgical approach was stratified by race and year. To adjust for confounding and estimate the association of covariates with approach, data were fit using multivariable binary logistic regression main effects model. Using a joint effects model, we evaluated whether the odds of a particular approach over time was differentially affected by race.

RESULTS

Of the 46 713 patients meeting inclusion criteria, 83% were white, with 7% black and 10% other. Over the study period, there was a decrease in the rate of open colectomy of about 5% P < .001, and increase in the rate of utilization of laparoscopic and robotic approaches (RC) P < .0001. After adjusting for confounders, black race was associated with open surgery P < .0001.

CONCLUSION

There is disparity in the utilization of MIS for diverticulitis. Further research into the reasons for this disparity is critical to ensure known benefits of MIC are realized across all races.

Racial and Ethnic Disparities in Obliterative Procedures for the Treatment of Vaginal Prolapse

OBJECTIVES

Although racial disparities are well documented for common gynecologic surgical procedures, few studies have assessed racial disparities in the surgical treatment of vaginal prolapse. This study aimed to compare the use of obliterative procedures for the treatment of vaginal prolapse across racial and ethnic groups.

STUDY DESIGN

This is a retrospective cohort study of surgical cases from 2010 to 2018 from the American College of Surgeons National Surgical Quality Improvement Program, a nationally validated database. Cases were identified by Current Procedural Terminology codes. Modified Poisson regression was used to calculate risk ratios and 95% confidence intervals, adjusting for potential confounders selected a priori.

RESULTS

We identified 45,865 surgical cases, of which 10% involved an obliterative procedure. In the unadjusted model, non-Hispanic Asian and non-Hispanic Black patients were more likely to undergo an obliterative procedure compared with non-Hispanic White patients (risk ratio [95% confidence interval], 2.4 [2.1-2.7] and 1.2 [1.03-1.3], respectively). These relative risks were largely unchanged when controlling for age, body mass index, diabetes, American Society of Anesthesiologists classification, and concurrent hysterectomy.

CONCLUSIONS

Although both obliterative and reconstructive procedures have their respective risks and benefits, the proportion of patients undergoing each procedure differs by race and ethnicity. It is unclear whether such disparities may be attributable to differences in preference or inequity in care.

Variation in Vaginal Hysterectomy Rates in an Integrated Healthcare System

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.

Racial Differences in Planned Hysterectomy Procedure Route

Background: Hysterectomies can be performed with a minimally invasive surgical (MIS) approach or a laparotomic (abdominal) approach. The objective of this study was to assess any racial differences in the likelihood of having a planned MIS hysterectomy. Materials and Methods: A prospective cohort study of women undergoing hysterectomy at Henry Ford Health System was conducted where laparotomic and MIS approaches are available to all patients. All procedures were performed between October, 2015, and August, 2017. For this study, women were asked to report demographic and insurance information and complete validated questionnaires from 2 weeks before hysterectomy and up to six additional times in the year after hysterectomy. Clinical and operative characteristics were collected from electronic health records. Logistic regression and multinomial logistic regression models were applied to assess the association between race and the surgical approach. Results: Analyses included 235 White women and 196 Black women. Black women were less likely to have any MIS planned for their hysterectomy (odds ratio [OR] = 0.46, 95% confidence interval [CI] 0.3-0.71, p < 0.05), a laparoscopic hysterectomy (relative risk ratio [RRR] = 0.46, 95% CI 0.29-0.73, p < 0.05), or a vaginal hysterectomy (RRR = 0.45, 95% CI 0.25-0.81, p = 0.01) compared with White women. After adjusting for confounders, uterine weight and indication for surgery was fibroids, these racial differences did not remain statistically significant (MIS vs. abdominal [adjusted odds ratio {aOR} = 0.93, 95% CI 0.55-1.57, p = 0.79], laparoscopic vs. abdominal [adjusted relative risk ratio {aRRR} = 0.89, 95% CI 0.52-1.51, p = 0.54], and vaginal vs. abdominal [aRRR = 1.22, 95% CI 0.61-2.45, p = 0.58]). The associations were not confounded by the baseline survey data from standardized questionnaires on depression, financial distress, and satisfaction with their decision. Conclusions: Black women were not less likely than White women to have planned an MIS hysterectomy after controlling for important confounding variables. These results emphasize the importance of considering all important confounders when examining racial differences.

Racial and ethnic representation in primary research contributing to pelvic organ prolapse treatment guidelines

INTRODUCTION AND HYPOTHESIS

To evaluate whether the studies contributing to the national treatment guidelines on pelvic organ prolapse adequately represent the racial and/or ethnic makeup of the American population.

METHODS

This analysis examines the racial and ethnic makeup of all primary study cohorts contributing to the American College of Obstetricians and Gynecologists/American Urogynecologic Society Practice Bulletin No. 214 on pelvic organ prolapse. References were excluded if they lacked a primary patient population or were from outside the US. Mean proportional representation of racial/ethnic groups was compared to the 2018 United States Census data on race/ethnicity. The representation quotient was also calculated to evaluate for relative representation of each group. Descriptive statistics were used.

RESULTS

Of the 110 references, 53 primary studies were included in the final analysis with 30 studies reporting on race/ethnicity. On average, 82% (SD = 15%) of study populations were White, while Blacks, Hispanics, and Asians represented 67% (SD = 7%), 4% (SD = 8%), and < 1% (SD = 1%), respectively, differing significantly from the 2018 US Census (p < 0.01.) The representation quotients for White women was 1.36, demonstrating a 36% overrepresentation, while Black, Hispanic, and Asian women were underrepresented among studies of all evidence levels, with representative quotients of 0.50, 0.23, and 0.09, respectively.

CONCLUSIONS

Our study demonstrates a significant underrepresentation of non-White populations in primary cohorts of studies contributing to the ACOG/AUGS Practice Bulletin No. 214 on POP. This analysis reinforces that more efforts are required to include and report on racial and ethnically diverse cohorts to better serve all patients.

Each Uterus Counts: A narrative review of health disparities in benign gynaecology and minimal access surgery

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.

Disparities in Access to High-Volume Surgeons Within High-Volume Hospitals for Hysterectomy

OBJECTIVE

To examine access to high-volume surgeons in comparison with low-volume surgeons who perform hysterectomies within high-volume hospitals and to compare perioperative morbidity and mortality between high-volume and low-volume surgeons within these centers.

METHODS

Women who underwent hysterectomy in New York State between 2000 and 2014 at a high-volume (top quartile by volume) hospital were included. Surgeons were classified into quartiles based on average annual hysterectomy volume. Multivariable models were used to determine characteristics associated with treatment by a low-volume surgeon in comparison with a high-volume surgeon and to estimate the association between physician volume, and morbidity and mortality.

RESULTS

A total of 300,586 patients cared for by 5,505 surgeons at 59 hospitals were identified. Women treated by low-volume surgeons, in comparison with high-volume surgeons, were more often Black (19.4% vs 14.3%; adjusted odds ratio [aOR] 1.26; 95% CI 1.09-1.46) and had Medicare insurance (20.6% vs 14.5%; aOR 1.22; 95% CI 1.04-1.42). Low-volume surgeons were more likely to perform both emergent-urgent procedures (26.1% vs 6.4%; aOR 3.91; 95% CI 3.26-4.69) and abdominal hysterectomy, compared with minimally invasive hysterectomy (77.8% vs 54.7%; aOR 1.91; 95% CI 1.62-2.24). Compared with patients cared for by high-volume surgeons, those operated on by low-volume surgeons had increased risk of a complication (31.0% vs 10.3%; adjusted risk ratios [aRR] 1.84; 95% CI 1.71-1.98) and mortality (2.2% vs 0.2%; aRR 3.04; 95% CI 2.20-4.21). In sensitivity analyses, differences in morbidity and mortality remained for emergent-urgent procedures, elective operations, cancer surgery, and noncancer procedures.

CONCLUSION

Socioeconomic disparities remain in access to high-volume surgeons within high-volume hospitals for hysterectomy. Patients who undergo hysterectomy at a high-volume hospital by a low-volume surgeon are at substantially greater risk for perioperative morbidity and mortality.