Discrepancies between racial/ethnic groups and choice of hysterectomy procedures

Why white women receive more "minimally invasive" hysterectomies than others?

Key Points

• Highlights:
• Although eligible for minimally invasive hysterectomy, women from minority groups were more likely than white women to receive abdominal hysterectomy, which implicates health disparities.

Importance:

• Hysterectomy by minimally invasive surgery, i.e, vaginal, laparoscopic/robot-assisted hysterectomy is typically preferred over abdominal hysterectomy for benign conditions owing to a quick return to normal activities, fewer complications, and a shorter stay in the surgical clinics.
• More open hysterectomies being practiced for women of African American and ethnic minorities has been a source of concern. 

What's done here:

• Hospital discharge data from the State Ambulatory Surgery Databases from several states of the USA were evaluated. 
• Adult women who underwent hysterectomy for benign gynecologic conditions between 2010 and 2014 were included in this retrospective study. 
• A marginal structural log-binomial regression statistical model was used to estimate adjusted standardized prevalence ratios for minimally invasive versus abdominal hysterectomy
• Data were controlled for clustering among the hospitals. 

Key results:

• Although being eligible for minimally invasive hysterectomy, women of African American and ethnic minorities were more likely to receive abdominal hysterectomy compared to whites. 
• The percentages of all women undergoing abdominal hysterectomy were highest at hospitals serving mainly African-American populations.
• This may also lead to disparities in outcomes, in part owing to the higher complications in open surgeries and suggest that minority women might experience lower access to minimally invasive surgery. 

Limitations:

• Uterine size, leiomyoma characteristics, body mass index, obesity, and patient preference, were not examined.
• In addition, state- and hospital-level variation to provide race/ethnicity information could lead to inconsistent data.

Lay Summary

Dr. Pollack and associates from Washington University, St.Louis, made multistate research regarding the patient profile in hysterectomies and published their results in the 2019 December issue of "The Journal of Minimally Invasive Gynecology".

The most frequently performed nonobstetric surgery in women is hysterectomy, with more than 400 000 procedures for benign gynecologic conditions performed each year in the US. Minimally invasive surgery, i.e. vaginal, laparoscopic/robot-assisted hysterectomy is preferred over abdominal hysterectomy for benign conditions owing to a quick return to daily activities, fewer complications, and shorter hospital stay.

It has been claimed that hysterectomy surgical routes vary by race/ethnicity revealing a health disparity among patients. Specifically, nonwhite and African American women less likely to benefit from minimally invasive surgeries than white women.

To investigate the above assumption, hospital records from the State Ambulatory Surgery Databases from Colorado, Florida, Maryland, New Jersey, and New York were evaluated. Adult women who underwent a hysterectomy for benign gynecologic conditions between 2010 and 2014 were included in this retrospective analysis. A marginal structural log-binomial regression model was used to estimate adjusted standardized prevalence ratios for minimally invasive vs abdominal hysterectomy, controlling for clustering within hospitals. Hysterectomies were classified as abdominal, vaginal, or laparoscopic, inclusive of robotic, according to the International Classification of Disease codes.

After excluding women with obstetric delivery, complication/history of delivery, cancer, obesity, leiomyomas, or previous abdominopelvic surgery, the final analytic cohort included 133 082 women aged ≥18 years. Despite focusing on women likely eligible for minimally invasive surgery, 22% of the women underwent abdominal hysterectomy. Nonwhite women were more likely than White women to undergo an abdominal hysterectomy, which is associated with more complications, pain, and longer stay. Additionally, hospital factors that might also contribute to continued use of abdominal hysterectomy and disparities in surgical routes were identified.

The disparities found in this study could increase over time if laparoscopic hysterectomy rates continue to increase more slowly for African American women.

"Future studies need to examine what distinguishes hospitals providing a lower quality of care as demonstrated by higher use of abdominal hysterectomy from those providing a higher quality of care with greater use of minimally invasive surgery and barriers to access to high-volume centers and/or surgeons" concluded the researchers.

Research Source: https://pubmed.ncbi.nlm.nih.gov/31518712/