Socioeconomic and Racial Predictors of Undergoing Laparoscopic Hysterectomy for Selected Benign Diseases: Analysis of 341 487 Hysterectomies

doi:10.1016/j.jmig.2007.07.014

Journal of Minimally Invasive Gynecology

Volume 15, Issue 1, January–February 2008, Pages 11-15

https://doi.org/10.1016/j.jmig.2007.07.014 Get rights and content

Abstract

Study Objective

Socioeconomic status and race are important determinants of health care access in the United States. The purpose of our study was to evaluate whether these factors influence use of laparoscopic hysterectomy for management of benign gynecologic diseases.

Design

Retrospective cohort study (Canadian Task Force classification II-3).

Setting

Data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 1998 to 2002.

Patients

All records of women with primary discharge diagnosis of uterine leiomyomas or menorrhagia who underwent hysterectomy (laparoscopy or abdominal) were included in the study.

Interventions

Race (Caucasian, African-American, Hispanic, or other), median household income (<$25 000, $25 000–$34 999, $35 000–$44 999, or ≥$45 000), and insurance status (private, Medicare, Medicaid, or other) were evaluated as determinants of laparoscopic surgical intervention. Unconditional logistic regression was used to estimate likelihood of laparoscopic approach to hysterectomy.

Measurements and Main Results

Of 341 487 records for hysterectomy, 295 857 were performed by abdominal and 45 630 by laparoscopic approach. In adjusted analyses, African-Americans, Hispanics, and other ethnicities were less likely to undergo laparoscopic hysterectomy; adjusted OR (95% CI): 0.44 (0.42–0.45), 0.58 (0.55–0.61), and 0.68 (0.64–0.72), respectively, as compared with Caucasians. As compared with women with median income of less than $25 000, laparoscopic approach was more commonly performed on women with median household income $25 000 to $34 999, 1.18 (1.10–1.26); $35 000 to $44 999, 1.13 (1.0–1.21); and $45 000 and above, 1.14 (1.06–1.22). As compared with women with Medicaid, laparoscopic approach was more likely to be performed on women with private insurance: 1.45 (1.42–1.62).

Conclusion

In the United States, median household income, insurance status, and race appear to be important independent determinants of access to laparoscopic hysterectomy for benign diseases.

Section snippets

Materials and Methods

We performed a retrospective cohort study using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS), 1998 to 2002. Each annual data set contains approximately 7 million records of patient in hospital including demographic data, discharge diagnoses, procedure codes, and vital status at discharge for respective admission. Records included in the data sets are representative samples of approximately 20% of admissions to United States hospitals. Diagnostic

Results

Age and other baseline characteristics of patients are depicted in Table 1, Table 2. Most women were older than 40 years, Caucasian, with median household income of $25 000 or more, and had private insurance. The patient population did not have comorbid diseases, and most procedures were performed in an urban setting on an elective basis.

Table 3 shows adjusted effect of race, median household income, and insurance provider on laparoscopic hysterectomy. Compared with Caucasians,

Discussion

Differences in access between racial and socioeconomic groups are well-established barriers to health care [1, 2, 3, 5, 12, 13, 14]. In a study evaluating use of selected surgical procedures in California, the authors reported that residents of South Central Los Angeles were less likely to undergo percutaneous transluminal coronary angioplasty, coronary artery bypass grafting, carotid endarterectomy, and cesarean sections [12]. Differential access to surgical procedures was thought to be, in

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Cited by (66)

Racial disparities in uterine fibroids and endometriosis: a systematic review and application of social, structural, and political context
2023, Fertility and Sterility
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.
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.
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.
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.
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.
The Impact of Race and Ethnicity on Use of Minimally Invasive Surgery for Myomas
2022, Journal of Minimally Invasive Gynecology
Citation Excerpt :
This study, with its specific focus on myoma surgery and incorporation of more granular data than large databases afford, adds to an important body of evidence revealing racial and ethnic disparities in gynecologic surgery. In our cohort, black and Hispanic patients had decreased odds of undergoing MIS, even when controlling for important confounders such as myoma burden and insurance type—a finding consistent with previous literature [9,11,12,16]. These disparities were particularly pronounced for patients undergoing hysterectomy.
To determine whether minimally invasive surgery (MIS) for uterine myomas is used differentially based on race and ethnicity.
Retrospective cohort study.
Quaternary care academic hospital in the United States.
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.
Hysterectomy, myomectomy.
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.
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.
Trends and predictors of hysterectomy prevalence among women in the United States
2022, American Journal of Obstetrics and Gynecology
Hysterectomy is the most common nonobstetrical medical procedure performed in US women. Evaluating hysterectomy prevalence trends and determinants is important for estimating gynecologic cancer rates and management of uterine conditions.
This study aimed to assess hysterectomy prevalence trends and determinants using the Behavioral Risk Factor Surveillance System (2006–2016).
We estimated crude hysterectomy prevalences and multivariable-adjusted odds ratios and 95% confidence intervals for associations of race or ethnicity, age group (5-year), body mass index (categorical), smoking status, education, insurance, income, and US region with hysterectomy. Missing data were imputed. The number of women in each survey year ranged from 220,302 in 2006 to 275,631 in 2016.
Although overall hysterectomy prevalence changed little between 2006 and 2016 (21.4% and 21.1%, respectively), hysterectomy prevalence was lower in 2016 than in 2006 among women aged ≥40 years, particularly among non-Hispanic Black and Hispanic women. Current smoking (odds ratio, 1.38; 95% confidence interval, 1.35–1.41), increasing age (odds ratio, 1.40; 95% confidence interval, 1.39–1.40), living in the South compared with the Midwest (odds ratio, 1.36; 95% confidence interval, 1.34–1.39), higher body mass index (odds ratio, 1.26; 95% confidence interval, 1.25–1.27), Black race compared with White (odds ratio, 1.10; 95% confidence interval, 1.07–1.13), and having insurance compared with being uninsured (odds ratio, 1.26; 95% confidence interval, 1.22–1.30) were most strongly associated with increased prevalence. Hispanic ethnicity and living in the Northeast were most strongly associated with decreased prevalence (odds ratio, 0.73; 95% confidence interval, 0.70–0.76; odds ratio, 0.67; 95% confidence interval, 0.65–0.69).
Nationwide hysterectomy prevalence decreased among women aged ≥40 years from 2006 to 2016, particularly among non-Hispanic Black and Hispanic women. Age, non-Hispanic Black race, having insurance, current smoking, and living in the South were associated with increased odds of hysterectomy, even after accounting for possible explanatory factors. Further research is needed to better understand associations of race and ethnicity and region with hysterectomy prevalence.
Patient Characteristics Associated with Access to Minimally Invasive Gynecologic Surgery: Changes during the COVID-19 Pandemic
2022, Journal of Minimally Invasive Gynecology
Citation Excerpt :
Each demographic characteristic was reviewed, and the minority category was given the value of 1 point and then all points were summated per participant. Minority value assignments were based on existing literature about SDOH [2,6,9,10]: nonwhite race, Hispanic ethnicity, primary language non-English, male sex, gender identified as transgender, unemployed, no insurance or public insurance, marital status of single, living in an area with a lower proportion of housing owned, a greater proportion of poverty, a higher proportion of African Americans, a lower portion of adults who completed high school, a lower number of housing units per square kilometer, a higher income inequality, and living in an area with a lower number of persons per square kilometer were given the value of 1. Scores in this study population ranged from 0 to 14.
To evaluate patient characteristics that affect access to minimally invasive gynecologic surgery (MIGS) subspecialty care and identify changes during the coronavirus disease 2019 pandemic.
Retrospective cohort study of patients referred to MIGS from 2014 to 2016 (historic cohort) compared with those referred to MIGS in 2020 (pandemic cohort). Primary outcome was the interval between referral and first appointment.
Single-institution academic MIGS division.
Historic cohort (n = 1082) and pandemic cohort (n = 770).
Not applicable.
Demographics and socioeconomic variables (race, ethnicity, language, insurance, employment, and socioeconomic factors by census tract) and distance from hospital were compared between historic and pandemic cohorts with respect to referral interval using the chi-square, Fisher exact tests, and logistic regression. After adjusting for referral indication, being unemployed and living in an area with less population density, less education, and higher percentage of poverty were associated with a referral interval >30 days in the historic cohort. In the pandemic cohort, only unemployment persisted as a covariate associated with prolonged referral interval and new associated variables were primary language other than English (odds ratio, 3.20; 95% confidence interval [CI], 1.60–6.40) and “other” race (odds ratio, 2.22; 95% CI, 1.34–3.68). The odds of waiting >30 days increased by 6% with the addition of 1 demographic risk factor (95% CI, 1.01–1.10) and by 17% for 3 risk factors (95% CI, 1.03–1.34) in the historic cohort whereas no significant intersectionality was identified in the pandemic cohort. Average referral intervals were significantly shorter during the pandemic (31 vs 50 days, p <.01). Telemedicine appointments had a significantly shorter referral interval than in-person appointments (27 vs 47 days, p <.01). Of patients using telemedicine, a greater proportion were non-Hispanic, English speaking, employed, privately insured, and lived further from the hospital (p <.05).
Time from referral to first appointment at a tertiary-care MIGS practice during the coronavirus disease 2019 pandemic was shorter than that before the pandemic, likely owing to the adoption of telemedicine. Differences in socioeconomic and demographic factors suggest that telemedicine improved access to care and decreased access disparities for many populations, but not for non–English-speaking patients.
Rethinking Disparities in Minimally Invasive Myomectomy: Identifying Drivers of Disparate Surgical Approach to Myomectomy Between African American and White Women
2022, Journal of Minimally Invasive Gynecology
To identify drivers of disparities among patients undergoing surgical management of myomas when stratified by self-identified patient race.
This is a retrospective institutional review board–approved chart review of all patients who underwent a myomectomy at a large academic center. Surgical approach to myomectomy was classified as abdominal, laparoscopic, or robotic-assisted laparoscopic. Myoma burden was quantified preoperatively using uterine volume, intraoperatively by number of myomas listed on operative report, and postoperatively by myoma weight from pathology reports.
A large tertiary care hospital containing a comprehensive myoma treatment center.
A total of 265 white patients and 121 African American patients who underwent a myomectomy between January 2012 and October 2018 were included in the study population.
Abdominal, laparoscopic, and robotic-assisted myomectomy. Laparoscopic and robotic-assisted myomectomy were classified as minimally invasive myomectomy. Multivariable logistic regression models and a propensity score matching algorithm were used to match African American (AA) women and white women for myoma burden.
A total of 386 women were included in the study. AA women (31%; n = 121) had higher myoma burden than white women by preoperative imaging (AA: 36% with 3 or more myomas; white: 19% with 3 or more myomas; p <.01) and operative report (>8 AA: 31% vs white 13%; p <.01). Despite this, AA women underwent minimally invasive myomectomy at similar rates as compared with white women when adjusted for myoma burden, body mass index, preoperative hematocrit, hypertension, and surgical indication (adjusted odds ratio 1.3; 95% confidence interval, 0.8–2.2 myomas; p <.01). Sensitivity analysis using propensity score matching found similar results.
In this population, AA women had a higher myoma burden than white women. When matched for myoma burden, however, there was no statistically significant difference between rates of minimally invasive myomectomy and abdominal myomectomy. This finding was consistent when controlling for myoma burden measured by preoperative, intraoperative, or postoperative methods of measurement. Further studies are needed to better characterize this disparity at other hospitals and to investigate ways to increase access and equity among patients undergoing minimally invasive myomectomy.
Each Uterus Counts: A narrative review of health disparities in benign gynaecology and minimal access surgery
2021, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
We identified eight US studies [12,14,15,16,18,19,30,27] comparing rates of MIH in patients with different insurance providers (Table 2). Seven of these studies [12,14,15,16,18,27,30] reported that patients on Medicaid had lower rates of MIH than those privately insured. Only two studies [12,14] found that patients on Medicare had lower rates of MIH than the privately insured.
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.
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.
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.
Extensive study from the US has demonstrated disparities in access to minimally invasive gynaecological surgery, whereas in the UK the data is infrequent, inconsistent and incomplete. Little is known about the influence of patient preference and counselling as well as institutional bias on health equity in gynaecology. Further research is necessary to identify interventions that mitigate these disparities in access and outcomes.

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: Available at www.sciencedirect.com and www.jmig.org

: The authors have no commercial, proprietary, or financial interest in the products or companies described in this article.

: Funded partially by the Society of Reproductive Surgeons.

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Journal of Minimally Invasive Gynecology

Abstract

Study Objective

Design

Setting

Patients

Interventions

Measurements and Main Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

References (17)

Insurance status and race represent independent predictors of undergoing laparoscopic surgery for appendicitis: secondary data analysis of 145,546 patients

J Am College Surg

Comparison of racial/ethnic disparities in adult immunization and cancer screening

Am J Prev Med

Laparoscopic hysterectomy for benign diseases

Best Pract Res Clin Obstet Gynaecol

Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases

J Clin Epidemiol

A new method of classifying prognostic comorbidity in longitudinal studies: development and validation

J Chron Dis

Variation in hysterectomy rates across small geographic areas of Massachusetts

Am J Obstet Gynecol

Total laparoscopic hysterectomy: preoperative risk factors for conversion to laparotomy

J Minim Invasive Gynecol

Socioeconomic differences in hysterectomy: the Wisconsin longitudinal study

Am J Public Health

Cited by (66)

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

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

Trends and predictors of hysterectomy prevalence among women in the United States

Patient Characteristics Associated with Access to Minimally Invasive Gynecologic Surgery: Changes during the COVID-19 Pandemic

Rethinking Disparities in Minimally Invasive Myomectomy: Identifying Drivers of Disparate Surgical Approach to Myomectomy Between African American and White Women

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

Original articleSocioeconomic and Racial Predictors of Undergoing Laparoscopic Hysterectomy for Selected Benign Diseases: Analysis of 341 487 Hysterectomies

Abstract

Study Objective

Design

Setting

Patients

Interventions

Measurements and Main Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

J Am College Surg

Am J Prev Med

Best Pract Res Clin Obstet Gynaecol

J Clin Epidemiol

J Chron Dis

Am J Obstet Gynecol

J Minim Invasive Gynecol

Socioeconomic differences in hysterectomy: the Wisconsin longitudinal study

Am J Public Health

Original article
Socioeconomic and Racial Predictors of Undergoing Laparoscopic Hysterectomy for Selected Benign Diseases: Analysis of 341 487 Hysterectomies