Although recent events have spurred much discourse regarding systemic racism, the issue of racism is old, very old. Unfortunately, our gynecologic surgery history is rooted in racism, with numerous documented procedures performed on enslaved women without their consent. Over the years, racism has continued to permeate gynecologic surgery in so far as access to quality care, patient outcomes, and inclusion in research. While racial disparities with regard to stage at diagnosis and survival of gynecologic malignancy has been documented, this discussion is outside the scope of this article.
Racial disparities in gyn surgery: The evidence
More data exist with regard to hysterectomy and racism than with any other gynecologic surgery. Most notably, a minimally invasive approach to hysterectomy is less likely to occur for minority women, even in universally insured patient populations and when controlling for factors predisposing patients to an abdominal approach.
Minority women undergo MIS for hysterectomy less often
Ranjit and colleagues assessed hysterectomy data between 2006 and 2010 from National TRICARE Prime and Prime Plus data to evaluate if racial differences existed in a universally insured population of US Armed Services members and their dependents. African American patients were significantly less likely than White patients to undergo a total vaginal hysterectomy (relative risk ratio [RRR], 0.63; 95% confidence interval [CI], 0.58–0.69) or total laparoscopic hysterectomy (RRR, 0.65; 95% CI, 0.60–0.71) compared with abdominal hysterectomy. Asian patients were also less likely to receive the vaginal (RRR, 0.71; 95% CI, 0.60–0.84) or laparoscopic (RRR, 0.69; 95% CI, 0.58–0.83) approach to hysterectomy than White patients.1 These findings remained when controlled for surgery indication, suggesting that racial inequity was not attributed solely to preoperative patient factors. However, the authors could not control for specific patient factors such as body mass index and uterine weight.
Katon and colleagues reviewed data on patients who underwent hysterectomy for uterine fibroids at a Veterans Affairs hospital and found 99 excess abdominal hysterectomies were performed among Black women compared with White women. Despite controlling for predisposing factors related to abdominal surgery, facility, and geography (teaching hospital, higher volume hysterectomy), Black women were still less likely to undergo minimally invasive hysterectomy.2 The difference in approach between both groups remained largely unexplained.2
Pollack and colleagues reviewed hysterectomy data from Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery Databases between 2010 and 2014 from Colorado, Florida, Maryland, New Jersey, and New York. They found that African American and Hispanic women were less likely to undergo vaginal (adjusted standardized prevalence ratio [aPR], 0.93; 95% CI, 0.90–0.96 and aPR, 0.95; 95% CI, 0.93−0.97, respectively) and laparoscopic hysterectomy (aPR, 0.90; 95% CI, 0.87−0.94 and aPR, 0.95; 95% CI, 0.92−0.98, respectively) than White women. Asian/Pacific Islander women were less likely to undergo vaginal hysterectomy (aPR, 0.88; 95% CI, 0.81−0.96). They also found that hospitals providing care to more racial/ethnic minority women performed more abdominal and fewer vaginal procedures compared with other hospitals.3
Sanei-Moghaddam and colleagues reviewed data from University of Pittsburgh Medical Center–affiliated hospitals and found that European-American women had 0.47 times lower odds of undergoing abdominal hysterectomy compared with ethnic/race minority group women. Also, traditional Medicaid and Medicare enrollees had 2- to 4-times higher odds of having an abdominal hysterectomy compared with patients with commercial insurance.4 Evidently, insurance and payer status and hospital, along with race, were associated with abdominal hysterectomy.
Postop complications higher among Black women. One study of the National Surgical Quality Improvement Program 2015 hysterectomy database found that Black women were more likely to undergo open hysterectomy than White women despite controlling for patient factors associated with open hysterectomy, including uterine weight (adjusted odds ratio [aOR], 2.02; 95% CI, 1.85–2.20).5 Black women also were more likely to develop both minor and major postoperative complications despite controlling for route of hysterectomy (major complications aOR, 1.56; 95% CI, 1.25–1.95 and minor complications aOR, 1.27; 95% CI, 1.11–1.47). Their study was limited by inability to control for surgeon volume and experience and hospital-specific factors.5
Hospital size and surgeon volume found to play a role in disparities. In an effort to address hospital and surgeon factors and racial disparities in minimally invasive hysterectomy, Mehta and colleagues evaluated an all payer system in Maryland. Black (reference White; aOR, 0.70; 95% CI, 0.63–0.78) and Hispanic patients (aOR, 0.62; 95% CI, 0.48–0.80) were less likely to undergo minimally invasive hysterectomy. Patients who had surgery at small- and medium-sized hospitals or by medium-volume surgeons (medium vs high volume: OR, 0.78; 95% CI, 0.71–0.87) were also more likely to undergo open hysterectomy.6 The study authors suggest increased utilization of higher volume surgeons for referrals or to assist lower-volume surgeons as potential solutions to address racial disparities.6
Continue to: Surgical outcome disparities extend beyond hysterectomy route...